Studien haben den Expertenstreit um die Wirksamkeit von Therapien gegen Depressionen neu entfacht. Kritiker glauben, dass Medikamente nicht mehr helfen als Behandlungen mit Placebos.
Auf den ersten Blick sieht es nach einer dringend benötigten guten Nachricht für die Verfechter von Antidepressiva aus: Zwei der am häufigsten verschriebenen Mittel seien «bei Depressionen wirksam», bilanziert eine unlängst erschienene Auswertung im renommierten Fachblatt «Archives of General Psychiatry», die auf Daten von gut 9000 Studienteilnehmern beruht. Die Studie bestätige frühere Ergebnisse nicht, nach denen Antidepressiva ausser bei schweren Depressionen kaum helfen würden, schreibt das Autorenteam um Robert Gibbons von der University of Chicago.
Was für Aussenstehende überraschend klingen mag, könnte für manche Psychiater tatsächlich so etwas wie eine Entwarnung sein. Der Grund: In den letzten Jahren zeigten verschiedene Studien, dass die Wirkung von Antidepressiva im Vergleich zu Placebos bescheiden ist – und haben damit unter Fachleuten eine Kontroverse ausgelöst. Doch die neue Studie wird die Auseinandersetzungen nicht beenden. Im Gegenteil, wie die Reaktion von Irving Kirsch zeigt. Der Psychologieprofessor von der University of Plymouth findet in seinen Studien bei Antidepressiva seit Jahren eine bestenfalls bescheidene Wirksamkeit. Zur Analyse des Gibbons-Teams vermerkt er trocken, deren Ergebnisse seien auch nicht besser. «Der einzige Unterschied zwischen ihren Resultaten und unseren ist, dass sie es einen Erfolg nennen.»
Der Expertenstreit ist für viele Menschen von enormer Bedeutung. Etwa jeder Sechste erkrankt mindestens einmal im Leben an einer Depression. Antidepressiva tragen mit dazu bei, dass Medikamente gegen psychische Erkrankungen in der Schweiz heute die Verschreibungsstatistik anführen. Mit einem Marktanteil von fast 17 Prozent liegen sie deutlich vor Mitteln gegen Herzprobleme oder Infektionen. Besonders häufig werden Antidepressiva älteren Menschen verordnet. Doch ausgerechnet in dieser Altersgruppe kann auch die Gibbons-Studie keinen Nutzen belegen.
Die Mittel haben es schwer in Untersuchungen, weil etwa 30 Prozent der Depressiven auch mit einem Placebo aus der Krise herauskommen. Daran gemessen wirkt die Erfolgsquote der Medikamente von 43 Prozent in der neuen Studie recht mässig. Ein Dilemma für Fachleute wie Erich Seifritz von der Psychiatrischen Universitätsklinik Zürich. Er ist überzeugt, dass «die realen Effekte grösser sind». Allerdings lassen auch die Wirkungen unter Alltagsbedingungen zu wünschen übrig, wie die realistisch angelegte Star-D-Studie zeigt. In diesem Grossversuch des amerikanischen National Institute of Mental Health (NIMH) hatte nach einem Jahr nur jeder Vierte seine Depression ohne Rückfall überwunden.
Dazu kommen die Nebenwirkungen. Die in den 80er-Jahren eingeführten Wirkstoffe quälen die Patienten zwar weniger als ihre Vorgänger mit Mundtrockenheit, Verstopfung und Sehproblemen. Doch auch Fluoxetin (Prozac) und seine Verwandten fordern ihren Preis. Schon lange ist bekannt, dass sie nicht nur für Magenbeschwerden und mangelnden Appetit sorgen können, sondern auch für sexuelle Probleme. Und je genauer Forscher hinsehen, desto mehr verborgene Risiken finden sie.So untersuchten Forscher mehrerer taiwanischer Universitäten um Chia-Ming Chang, wie sich Antidepressiva auf die Fahrtauglichkeit auswirken. Ergebnis der gerade online vorab veröffentlichten Studie mit Daten von über 36’000 Autofahrern: Wer die Pillen schluckt, verursacht fast doppelt so oft einen Unfall. Um auszuschliessen, dass dafür die Depressionen selbst verantwortlich sind, erfassten die Forscher die Besuche bei Psychiatern und korrigierten ihre Ergebnisse entsprechend.
Abwägen bei Schwangeren
Gleich eine ganze Welle von neuen Studien legt Vorsicht beim Einsatz in der Schwangerschaft nahe. Bei den werdenden Müttern erhöhen Antidepressiva die Gefahr, an Bluthochdruck zu erkranken. Bei den Babys wiederum wird häufiger Lungenhochdruck registriert. Ausserdem wächst die Gefahr einer Frühgeburt. Andererseits ist eine unbehandelte Depression nicht nur für die Mutter schlecht, sondern auch für das Baby. Es wächst im Mutterleib nicht so gut, und nach der Geburt tun sich depressive Mütter oft schwer, auf die emotionalen Bedürfnisse ihres Kindes einzugehen. Für Seifritz ist die «medikamentöse Therapie immer ein Abwägen zwischen verschiedenen Risiken für Mutter und Kind». Seiner Meinung nach gehört die Behandlung von Schwangeren und Stillenden mit Depressionen in die Hand des Facharztes für Psychiatrie und Psychotherapie, oder zumindest sollte ein solcher in die Therapieentscheidungen einbezogen werden.
In jedem Fall besteht eine zeitgemässe Depressionstherapie nicht nur aus Pillen. Darüber sind sich die meisten Fachleute einig, auch wenn in der Praxis viele Patienten allenfalls noch ein paar tröstende Worte vom Arzt bekommen. Bei leichten Depressionen kann zunächst sogar ganz auf Medikamente verzichtet werden. Bessert sich der Zustand nicht, empfehlen Experten Antidepressiva, Psychotherapie und soziale Unterstützung zu kombinieren.
Sport statt Psychotherapie?
Solch eine umfassende Strategie ist momentan die beste Wette. Wie sehr und vor allem warum die kombinierten Massnahmen helfen, ist allerdings eine andere Frage. Skeptiker Kirsch hat dazu gerade zusammen mit Arif Khan eine neue Analyse veröffentlicht, die auf Daten von 24’000 Patienten beruht. Demnach schneidet die Kombination von Medikamenten und Psychotherapie in vielen Studien vor allem deshalb am besten ab, weil die Ärzte dies glauben und bei der Einschätzung des Therapieerfolgs wissen, wie der Patient behandelt wurde. Wissen sie es nicht, ist die Kombination Medikamenten oder Psychotherapie allein kaum noch überlegen. Und weder Medikamente noch Psychotherapie sind dann besser als Sport, Akupunktur oder Pseudobehandlungen.
Wenn so unterschiedliche Behandlungen aber gleich wirken, argumentieren die Forscher, kommt es womöglich gar nicht darauf an, was gegen Depressionen unternommen wird. Sie greifen damit eine These auf, die der renommierte Psychiatrie-Professor Jerome Frank vor einem halben Jahrhundert in seinem Buch «Die Heiler» entwickelt hat: Entscheidend sei, dass der Patient gründlich untersucht werde, eine Erklärung für sein Leiden erhalte, Hoffnung schöpfe und schliesslich ein therapeutisches Ritual mit einem anerkannten Experten praktizierte. Ob der Spezialist eine Arznei verabreicht oder Akupunkturnadeln sticht, ist nicht wichtig, solange der Patient daran glaubt. Mit dieser Erklärung der Erfolge der Depressionsbehandlung dürfte für weitere Diskussionen gesorgt sein.
A world-renowned professor has been suspended from work for questioning university recruitment policy, in a move which supporters argue is a threat to “academic freedom” and reveals a “culture of bullying” at the institution.
Hundreds of academics have joined in support of a psychology professor, Ian Parker, who was suspended for questioning Manchester Metropolitan University’s recruitment procedure. It has banned him from campus, contacting colleagues, and accessing his emails in a move which has led to a global outcry from fellow academics including Noam Chomsky.
Professor Parker sent an email to departmental staff as the representative for the University and College Union (UCU), questioning whether bosses had followed proper procedures in a recent staff appointment. His superiors accused Professor Parker of gross professional misconduct. He was asked to relinquish his office keys, and was suspended on full pay on 26 September.
A senior MMU staff member, who asked not to be named, said: „People are just astounded by the level of punitiveness and the over-the-top approach by the management.“
Explaining the need for anonymity, the staff member added: „That’s the whole point about the climate of bullying at MMU: anyone [speaking out] would be instantly sacked. People face gross misconduct charges for minor alleged infractions.“
An online petition on behalf of Professor Parker has attracted 3,000 signatures from academics. Supporters have also sent letters of protest to MMU vice-chancellor Professor John Brooks. One letter, signed by 75 academics including Mr Chomsky, says it is „a serious matter when a university takes such unusual disciplinary steps against one of its members, an academic with a worldwide reputation, who brings considerable credit to UK psychology and to his own institution.“
Professor Parker, who is continuing to meet students off-campus, said: „I joined the university in 1985 and I’m very unhappy that the reputation of MMU has suffered, and my own reputation as well. The support has been very sustaining for me and very sustaining for my students.“
The UCU said: „We believe the university’s decision to suspend Ian Parker was heavy-handed and disproportionate, and a misuse of the suspension procedure.
UCU said it was also preparing a legal case for Christine Vie, a senior UCU officer at MMU, made redundant as the only member of staff not found alternate employment when her department was restructured in July. They will argue unfair dismissal and victimisation on the grounds of trade union activity at an employment tribunal.
The university insist that Professor Parker’s students have been supported, with alternative teachers and research supervisors appointed.
But Claire Parlane, a PhD student who Parker was supervising, said: „Ian Parker’s research students have been effectively suspended as well. I think it’s disgusting. I think it’s an egregious disregard for everything university tuition is supposed to be about. “
A spokesperson for MMU said: „We cannot and do not comment on individual cases. We have over 4,000 staff and have recently been awarded Investors in People Gold standard, one of only five universities in the UK to be awarded this. We refute any allegations or accusations of bullying.“
When we were drafting language to go into the Convention on the Rights of Persons with Disabilities, and throughout the negotiations, we avoided any specific mention of psychiatry, psychiatric institutions or mental health. Instead we framed all the issues of our community in terms of non-discrimination in the enjoyment of human rights, with an eye to how specific applications of these principles would logically entail the abolition of forced psychiatry.
The reasons for this choice were: to call attention to the underlying principles of fairness and justice rather than have a free-for-all debate on whether forced psychiatry is a good or a bad thing; to situate ourselves within the mainstream of disability and deliberately transform the mainstream to include and not exclude our issues; and to argue for the mutual application of “our” issues to all people with disabilities, and of all disability issues to ourselves. In this way we built solidarity within the disability community, strengthened disability rights concepts and principles, and contributed to the treaty’s overall effect of mainstreaming people with disabilities into the human rights framework.
When the treaty was taking its final shape in the last negotiating sessions, I had to make the assessment of whether it gave us what we wanted or not. We fought hard to get the best possible language that we could, and in many respects the text fell short of what would have been ideal. At every stage, we could have chosen to keep participating in the process, or to withdraw and denounce it. We did threaten to withdraw our support for the treaty at a tense point in the negotiations when it wasn’t certain that our version of legal capacity would be passed. We were able to make this a credible threat because we spoke as leaders of the International Disability Caucus, and our departure would have been a blow to the countries who wanted buy-in from the disability community. But it was a power that we could not invoke lightly, and we also did not really want to scrap the treaty, we wanted it to be passed with the language that would give us what we needed.
So my test was, 1) Is this a compromise of language, or a compromise of substance? If it was writing “human wrongs” into the treaty (like allowing involuntary treatment) it clearly had to be denounced as this would have made the treaty not only worthless but harmful for us. And 2), Is there a legally sound interpretation that gives us what we want? If I could make a credible legally reasoned argument that the text means what we intended it to mean, and that it could not mean the opposite, that interpretation is favored by the canons of treaty interpretation as being in line with the object and purpose of the treaty to promote and protect the human rights of persons with disabilities. If that sounds nerve-wracking, it was. But I believe the decisions we made were correct ones.
Evaluating the text as it was adopted, with its various ambiguities, in the last negotiating session, I felt that we had succeeded, but that it would need work to ensure a good interpretation. It was not a static fact, did we win or lose, it was more as if there was a high probability that we had won, and this would only be determined in the future. Significantly, our own actions would have an impact on whether in the final analysis we had won or lost. Human rights treaty interpretation, like the negotiation of the CRPD itself, is highly amenable to advocacy by civil society organizations and individuals, and in the case of the CRPD the opinions of persons with disabilities and our self-representative organizations are emphasized. (This was the practice during the negotiations, and is incorporated as an obligation of governments in the implementation of the treaty, in Article 4.3.)
My position, and that of WNUSP, was to claim the CRPD as a victory and argue for the interpretation of particular provisions that mean the abolition of forced psychiatry. I was disappointed that many academics and non-governmental organizations that are not user/survivor-run took a more cautious stance, because I believe that it is a duty of human rights advocates to advocate the most favorable legally sound interpretation, and I cannot really understand why they would fail to do so. Many in the user/survivor community were also slow to understand and appreciate the potential of this treaty, but over the past 6 years since the adoption I am happy to say that the CRPD has become a guiding star in the work of our movement in many countries, with leading work going on in every region of the world.
In the past six years there has also been significant support from the UN affirming our interpretation, including most crucially observations made by the Committee on the Rights of Persons with Disabilities, which is the authoritative body designated to monitor and interpret countries’ compliance with the CRPD. The Committee’s observations on the reports of particular countries show how it is interpreting the treaty, and so these observations can be taken to apply to all countries that have similar problems. Here is what they said recently to China about abolishing forced psychiatry and transforming mental health policy and practices:
The Committee advises the state party to adopt measures to ensure that all health care and services provided to persons with disabilities, including all mental health care and services, is based on the free and informed consent of the individual concerned, and that laws permitting involuntary treatment and confinement, including upon the authorisation of third party decision-makers such as family members or guardians, are repealed. It recommends the state party to develop a wide range of community-based services and supports that respond to needs expressed by persons with disabilities, and respect the person’s autonomy, choices, dignity and privacy, including peer support and other alternatives to the medical model of mental health.
Here is what they said about legal capacity. Remember that saying we are “incapable” of making our own decisions because of a “mental illness” is one of the justifications used to impose forced treatment, to take away a person’s right to manage their money and many other abuses.
The Committee urges the state party to adopt measures to repeal the laws, policies and practices which permit guardianship and trusteeship for adults and take legislative action to replace regimes of substituted decision-making by supported decision making, which respects the person’s autonomy, will and preferences, in the exercise of one’s legal capacity in accordance with Article 12 of the CRPD. In addition, the Committee recommends the state party in consultation with DPOs to, prepare a blueprint for a system of supported decision-making, and legislate and implement it which includes:
a. Recognition of all persons’ legal capacity and right to exercise it;
b. Accommodations and access to support where necessary to exercise legal capacity;
c. Regulations to ensure that support respects the person’s autonomy, will and preferences and establishment of feedback mechanisms to ensure that support is meeting the person’s needs;
d. Arrangements for the promotion and establishment of supported decision-making.
Some people have asked me, what is supported decision-making and how do we do it? I would say that the first step is to ask people what kind of support they need, and then figure out how to make that happen. Supported decision-making is a principle of cooperation to respect individuals’ autonomy, and not another service to be set up and then provided to people who already are living so much of their lives in connection with services.
In the light of these recommendations coming out of the authoritative committee that monitors the CRPD, it is highly irresponsible for anyone to doubt that the CRPD prohibits forced psychiatry and requires governments to repeal the laws that allow these violations to be committed. Our movement should be questioning any organization or prominent leader, whether that person is a lawyer, mental health professional, or user/survivor advocate (or any combination of the above), who is still claiming that CRPD cannot be used to abolish forced psychiatry. And we should ask, “cui bono?” Who is benefiting from this silencing, and how?
It is also a fallacy if people think that the CRPD is simply too far from any country’s political reality to be used to abolish forced treatment. First of all, such thinking takes the existing political climate as a limit on human rights, contrary to what the human rights framework is all about. But more importantly, it may really be a U.S.-centric way of thinking. It is likely that countries with more respect for human rights treaties and the United Nations, and where psychiatry is a colonial imposition rather than a home-grown mega-industry, will be the first to advance in this way. In India, a government ministry has put out a proposed bill on the rights of persons with disabilities, based on the CRPD. Among other things, it would guarantee full legal capacity to all people, with a remedy against any act that questions or denies a person’s legal capacity, and it would phase out civil commitment in the mental health system. The bill provides for thoughtful, positive approaches to creating support for exercise of legal capacity and creating services responsive to the needs of people with psychosocial disabilities. Although the CRPD requires an immediate end to civil commitment, this would be a huge step beyond what any other country has done so far. At the same time however, another ministry put forward a mental health bill that has all the standard provisions allowing involuntary commitment and involuntary treatment, and according to activists in India would actually make existing standards worse. So our colleagues held a “dharna” outside the ministry to protest the mental health bill, and they are getting decent media coverage. They have strong mutual support and solidarity with the disability movement; as we have seen this was also one of the key factors in the CRPD negotiations.
I believe that one of the underlying reasons it is difficult to move through the obstacles to fully embrace the CRPD and fight for our rights, is that discrimination continues to affect us on many levels. We have accommodated in some ways to a system that hurts us – not just the mental health system but the legal system that supports these violent acts and the society that condones them. It can be painful to change, to shift gears, to move in different ways. It is unfamiliar and uncertain, we may be acutely aware of our shortcomings and lack confidence. I struggle with this myself in the process of bringing this treaty more and more fully into the world, and continue to redefine my role in relation to the advocacy, so that more and more I am “leading from behind,” supporting others to develop the strategies and tactics that will get us where we are going, creating spaces where the discussion can happen to spark ideas that someone will be able to take up where the conditions are right. I especially want to teach as much as possible of what I know about the CRPD and human rights, as one of the five activity areas identified by the Center for the Human Rights of Users and Survivors of Psychiatry – ensuring good interpretation of the CRPD, law reform, human rights monitoring and enforcement, human rights education, and extending the analysis in related areas (which at the moment include the rights of older persons and the rights of prisoners). In struggle and solidarity, I would like to see more of our organizations in the U.S. survivor/peer/consumer/client movement take up the CRPD as intended, and cooperate to secure our full human rights including the abolition of forced psychiatry. We are at a crucial time in history when our choices matter. Even if you do not know how to go about making this change, at least know that it is part of the way here already.
On October 6 I gave a lecture to the American Psychiatric Association Institute on Psychiatric Services in New York City, entitled “Mental Diversity: 13 Practical Innovations To Improve Recovery Outcomes for Schizophrenia and Bipolar.” You can listen on the Beyond Meds website here:
Afterwards I was humming with energy and had a day in New York before heading back to Portland, so in a sleep-deprived state I wandered over to the Museum of Modern Art. One of the exhibits was a retrospective of the Brothers Quay, whose remarkable stop motion surrealist films have fascinated me for years. The show title? “On Deciphering the Pharmacist’s Prescription for Lip-Reading Puppets.” It was that kind of week.
How did the APA talk go? Overall a success– the audio went viral on the internet, and the talk itself was so crowded we had to move to a larger room — more than 70 psychiatrists and behavioral healthcare professionals attended. Afterwards many stepped up to shake my hand and congratulate me: I was told by two people I was a gift to the conference, asked to present at a Grand Rounds, encouraged to do a TED talk, thanked for my compassionate response to a question about forced treatment, and invited to do more trainings in the future. I even met several psychiatrists who are Madness Radio listeners. Psychiatry is clearly not a monolithic profession and many in it are beginning to think differently.
This individual support was encouraging, because not all of the comments and questions during the lecture were positive. One psychiatrist raised a puzzling criticism I hadn’t heard before: why focus on protesting psychiatry when the rest of society – such as nursing homes and medical care in general – is also deeply harmful? My response? I agreed with him, and told the crowd that we should be protesting everything – which got a big laugh. In my work I often build bridges with broader social justice movements, and it was ironic, and welcome, to hear this suggestion from a psychiatrist.
Later the doctor sitting next to him stood up and had a harsher response. Partly turning her back to me and facing the crowd, she essentially accused me of being a Scientologist (the anti-drug cult busy discrediting genuine efforts at mental health reform). I pressed her but she couldn’t be more specific or identify anything inaccurate in my talk, so I invited her to start a public exchange on the Mad In America blog. I reiterated my view that medications are often helpful to people, and by the end of the interaction she was more open to me. I was still a bit shaken.
Then afterwards two colleagues from NAMI, the National Alliance for the Mentally Ill, came up to me in the hotel lobby. They didn’t like that I had referred to the Senator Charles Grassley hearings on drug company corruption, which revealed publicly that more than 60% of NAMI’s budget was from pharmaceutical company funding. The colleagues said that NAMI has since reduced pharma funding to 30%, and that I was unfair for singling them out when other groups claiming to be grassroots also take drug money.
I’m always open to improving my facts and accuracy, but my 60% figure referred specifically to the Grassley hearings and I don’t feel a need for a public retraction. (I also can’t speak to whether NAMI has in fact reduced its reliance on pharma funding.) Our discussion continued, and I got a fascinating window into some of the inner politics of NAMI.
NAMI has a strategic initiative to reduce pharma funding, which is in part a public relations response but also a recognition, on some level, of the problems this kind of conflict of interest has created. There are more people with mental health diagnosis in NAMI leadership these days, some of whom who don’t subscribe to the medical model, drugs-and-force-are-the-answer, stay-on-Pharma-message approach that NAMI has taken.
It is true that other groups claiming to be grassroots also have the same conflict of interest problem with pharma funding, such as the Depression and Bipolar Support Alliance, Mental Health America, and Active Minds, and I’ll take to heart the suggestion that I name these groups more. I also recognize that Pharma is an easy target when the insurance industry, FDA, and other parts of the medical industry also deserve scrutiny.
In general I came away from the dialogue in the lobby encouraged that we were all trying to listen to each other, and feeling that there was real opening for feedback and discussion. Many people in NAMI are working, from the inside, to make change.
Though it does a lot I strongly oppose, and NAMI has played a key role in undermining effective mental heath care in the US, it’s worth repeating what I often say when the subject comes up: NAMI also does some things that I agree with, such as lobbying against social service budget cuts, challenging media stereotypes of violence, addressing mental health issues in prison, and providing support groups for families where no support would otherwise be available. I’ve met and worked with NAMI groups and members. I have no interest in vilifying NAMI, and I’m glad there are progressive people trying to reform the organization.
While I feel deeply wounded by much of what has come out of NAMI, I’m also trying to build bridges and create collaborations where possible. We do need to take strong, uncompromising stances, but I don’t like the Us versus Them approach on both sides. We are all humans and our politics and organizations are never simply monolithic. I hope we can all agree that our society and the mental health system can do much better to help people.
One of the points in my APA lecture that day was to call for “trialogue” between patients, family members, and professionals. Trialogues are making headway in Ireland and Austria, and I hope they can develop here. NAMI’s allegiance with pharma should be a topic in that dialogue – as should the aggression and scapegoating on both sides. Overall the exchange I had with the NAMI representatives was valuable (if a little nerve-wracking at first), and I appreciated the discussion they initiated. I hope we get a chance to continue the dialogue, and at the same time I don’t plan to hold back my views – and I wouldn’t expect them to either.
If you’ve heard me talk before you may notice I brought a different style to the APA. I was aiming to fit in to the research culture there, citing the best studies and journal articles I could find and loading the talk with information (I’m amazed I did the entire speech in an hour). The setting added to the formality, as I was standing at a podium on a raised platform and the room was arranged in rows like a university lecture hall. The two young professionals who introduced me and moderated the session were dressed in suits, and while I considered wearing the “Psycottish and Proud” t-shirt I bought at the Hearing Voices Congress last month, I settled on a simple dress shirt and jeans. I did my best to reach out to a crowd that might have been prepared for a fight, and by the end I think I managed to disarm opponents and win allies.
A highlight was telling everyone I was heading to the protest afterwards organized by Voices of the Heart and Mindfreedom. What better symbol of my efforts to break down walls and build bridges than being a lecturer at the American Psychiatric Association in the morning and then protesting the same American Psychiatric Association in the afternoon? (I headed to the SAMHSA-funded Alternatives conference the following week, so I guess I now have all the bases covered.) I invited all the psychiatrists in the room to join the protest, and it was great to see at least two of them show up at UN plaza for the rally, believe it or not. I’ll take it as a little sign of progress.