The US Substance Abuse and Mental Health Services Administration (SAMHSA) should be commended for its attempt to provide a basic understanding of recovery-oriented care, and its attempt to bring recovery-oriented practice into the mainstream of professional practice. To that end, it has produced a series of online training modules for peers, social workers, nurses, psychologists and psychiatrists. It has done this in collaboration with related national professional and peer organizations.
I have taken advantage of their availability recently to review them for content and to make some comparisons to what we are offering on the Mad in America Continuing Education project. In this blog, I will share my observations and focus on the medication module developed by SAMHSA in partnership with the American Psychiatric Association and the American Association of Community Psychiatrists. At the outset, I acknowledge that all three organizations represent a broad and often politically sensitive spectrum of members and political constituents. And it shows, as you will see.
First of all, SAMHSA should be commended for undertaking an important educational task with laudable goals. The medication segment, The Role of Medication in Recovery, emphasizes promoting partnership with patients and hope for recovery. It also provides at least some awareness of side effects issues.
Unfortunately, as might be expected from a federal agency that operates under constant pressure to be responsive to widely divergent advocacy organizations, and also under pressure related to the guild interests of the various mental health and addictions disciplines, SAMHSA usually takes a conservative, politically neutral position on most issues. And so, in spite of using now fairly popular words like "recovery" and "partnership with peers," these training efforts do not display an in-depth understanding of these key concepts.
What does this mean? In general, the materials present a very casual overview of psychiatric medications and their effectiveness. For example, a false claim was made—without any reference to a citation in the video—that they work for 50% of patients. Aside from the fact that there is no differentiation between the various categories of psychiatric drugs, the training doesn’t say a word about well-constructed mid- and long-term outcomes research that should be known by now to all serious students of the literature.
For the record, a few of these researchers are Martin Harrow, Courtenay Harding, Lex Wunderink, and Regitze Solling Wils. These studies call into serious question the ongoing use of psychiatric medications, and in some instances even their short-term use. More than three years ago, former NIMH Director Tom Insel was calling attention to the fact that many people diagnosed with schizophrenia and other psychoses could be better served by a more selective and limited use of drugs and more diverse treatments. The SAMHSA medication module shows no awareness of these changes in practice recommendations.
Given that it is common knowledge that the pharmaceutical corporations have been shown to falsify data (see Study 329 review by David Healy), and the frequency with which "research" is ghostwritten and funded by them, it is concerning that there is no critique of the industry's influence. It affects nearly every aspect of the development of treatment standards and has permeated the culture of prescribing professionals.
And while there is some minimal attention given to the side effects of psychiatric drugs (mostly about weight gain), the module doesn’t come close to providing a comprehensive review, one that could be the basis of informed consent. And none of the presenters noted the serious problems with reducing and withdrawing from medications if the patient chooses to do so. A careful informed consent protocol would cover all of these concerns.
Given that the course is entitled psychiatric medication, it also seemed odd that there was no information given about prescribing antidepressants, anti-anxiety agents, or combination of these and other psychoactive drugs. As Dr. Peter Goetzsche has shown with his meticulous meta analysis of all the literature related to these drugs, there is little effectiveness to them (beyond placebo) for most patients, and the risks of long-term use largely outweigh the benefits. Similarly, there is no attention to using medications with children, youth and seniors. At the very least, the title and scope of the module needs to reflect this omission.
Other critiques of the training would be that it assumes that diagnoses are valid and reliable. As Bob Whitaker and Lisa Cosgrove detail in Psychiatry Under the Influence, these were major problems in the development of the Diagnostic and Statistical Manual and they were again influenced by the relationship many of the DSM task force members had with the pharmaceutical industry.
Finally, there should have been at least mention of how medications interfere with working through issues of trauma and other psychological reasons for symptoms. The chemical imbalance hypothesis just does not hold water and diverts attention from the role of trauma and discrimination and the other determinants of health. This is, in fact, a problem with all of medicine as it is practiced in most healthcare settings. Stephen Schroeder's 2007 article in the New England Journal of Medicine makes these points crystal clear as he points out that only about 10% of health outcomes are attributable to medical interventions.
Unfortunately, I have to conclude that SAMHSA’s Recovery to Practice module on medications for psychiatrists is a very minimal and even misleading attempt at educating psychiatrists. It is certainly very acceptable to the guild interests of the American Psychiatric Association and disregards the best interests of people who may be discussing the use of psychiatric medications. It makes me all the more enthusiastic about the way in which the Mad in America Continuing Education project is "filling in the blanks" and will continue to do so as we expand our course offerings into early psychosis programs for young adults and, in the future, provide additional online trainings for evidence-based work with children, adolescents and seniors. Stay tuned.