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 Mosher
says this study showed that the people in the
Soteria replica fared as well as those who entered
the hospital, and "the cost savings of getting them
through the crisis were about 45 percent. In the
hospital, they stayed only 12 days, on average, and
they got them out mostly by being given so many
drugs they couldn't see straight. We didn't do
that. We actually tried to lower drugs and change
drugs and be more sensitive. And they got as much
better and it cost a lot less because the staff we
used were paraprofessionals." Over six months, it
cost about $19,900 per person on average to treat
the outpatients, versus $25,700 per person for
those dealt with in the hospital.
Although
Mosher described these findings and published them,
no new data about the original Soteria and Emanon
research reached print for years after his
departure from the National Institute of Mental
Health. Emanon had closed its doors in 1980, and
Soteria, after struggling to find revenue sources
other than the institute, finally came to an end in
1983. The institute had awarded a grant to analyze
the data collected between 1976 and 1982, but that
money didn't become available until 1989. Mosher
and a psychologist then began studying the
information, and "We finally published a paper
about the second part of the study in 1995. That's
a long time."
Today
Mosher says more than 40 publications have
described the study. Mosher thinks the "cleanest,
most important" finding was the outcomes for the
hospital and Soteria patients after six weeks (the
point at which neuroleptic drugs are known to be
most effective at reducing psychotic symptoms).
Comparing the outcomes at that point showed that
the Soteria subjects experienced as great a
reduction of their psychotic symptoms as did the
hospital patients, Mosher says. Whereas all of the
hospital patients received neuroleptic drugs, only
24 percent of the Soteria patients did during that
interval, "and really only 16 percent had enough to
be said to have had a possibly therapeutic course
-- two weeks or more." Mosher adds that the 76
percent of Soteria patients who got no drugs at all
did better than those who took some form of
medication. To Mosher, that means "If you can
construct the right kind of social environment for
newly diagnosed people who have schizophrenia, 76
percent will respond in that environment as well as
or better than they do to drugs."
Mosher's
move to San Diego had no direct connection to his
Soteria project. It came about as a result of the
work he did in Maryland, where he created a
community-based system of mental health care, one
that "worked extremely well for as long as they let
us do what we wanted." Mosher says the Montgomery
County supervisors then decided to hand over
various county programs to private contractors, a
move Mosher opposed. At about the same time, he
says, "San Diego recruited me to come out here and
change the San Diego system as I had the Montgomery
County one." In 1996, he started work as the
clinical director of mental health for the County
of San Diego. "Unfortunately, I landed here at the
same time that the San Diego County Board of
Supervisors was also bitten by the privatization
bug." The supervisors mandated that some kind of
managed care be implemented in San Diego County.
Mosher says that about 18 months after his arrival,
he submitted a plan that he believed would have
decentralized and improved the mental health care
system here. But it would have required hiring
about two dozen new staff members, a move that the
supervisors opposed. A year later, Mosher and the
county parted ways.
Sometime
in the year after his resignation, Mosher received
a routine notice from the American Psychiatric
Association asking him to pay his annual dues. He
says he'd begun having doubts about the cozy
relationship between the professional organization
and big pharmaceutical companies as far back as the
mid-1980s. "But you know, when you work at an
official job, it is really impolitic not to
be a member of the APA." When Mosher at last found
himself "deinstitutionalized," however, he felt
free to give full vent to his concerns. In December
1998, he fired off a letter of resignation to
Rodrigo Muñoz, a San Diego psychiatrist who
at the time was serving as president of the
national psychiatrists' organization.
The
letter made no attempt to be diplomatic. "At this
point in history, in my view, psychiatry has been
almost completely bought out by the drug
companies," Mosher stated. "The APA could not
continue without the pharmaceutical company support
of meetings, symposia, workshops, journal
advertising, grand rounds luncheons, unrestricted
educational grants, etc. etc.… Psychiatric
training reflects [the pharmaceutical
industry's] influence as well: the most
important part of a resident's curriculum is the
art and quasi-science of dealing drugs, i.e.,
prescription writing."
"No
longer do we seek to understand whole persons in
their social contexts," he continued. "Rather we
are there to realign our patients'
neurotransmitters." Mosher further charged that the
American Psychiatric Association had "entered into
an unholy alliance" with the National Alliance for
the Mentally Ill, the powerful group founded and
controlled by the parents of schizophrenics. "The
two organizations have adopted similar public
belief systems about the nature of madness. While
professing itself the 'champion of their clients,'
the APA is supporting non-clients, the parents, in
their wishes to be in control, via legally enforced
dependency, of their mad/bad offspring.…
'Biologically based brain diseases' are certainly
convenient for families and practitioners alike.
It is no-fault insurance against personal
responsibility. We are all just helplessly
caught up in a swirl of brain pathology for which
no one, except DNA, is responsible." Declaring that
he wanted "no part of a psychiatry of oppression
and social control," Mosher concluded by asking,
"Is psychiatry a hoax -- as practiced today?" and
answering, "Unfortunately, the answer is mostly
yes."
"I
was delighted that he wrote that letter,"
Muñoz declared in a recent interview at his
Hillcrest office. "This is Loren. It's a letter
addressed to psychiatry. It's a perfect example of
how he thinks." Muñoz characterizes that
thinking by saying, "Loren is a
stargazer."
Muñoz,
in contrast, is a man who's very much grounded in
the political realities of medicine. A
native of Colombia, he came to the United States
hoping to do research on schizophrenia and soon
thereafter wound up working in a laboratory at
Yale. For the past 25 years, he's had a clinical
practice in San Diego, and although he's no longer
head of the American Psychiatric Association, he's
the current president of the San Diego County
Medical Society. "There is plenty of evidence that
there are structural changes in the brains of
schizophrenics," Muñoz says. "There is no
doubt. It's clear that those changes may not be the
same for all the patients, and a specific change
may not exist in a given patient. But when you take
all these patients together, you see that those
brains are not typical. It's fairly clear that we
are gradually advancing to the point when we will
be able to pinpoint functional and structural
changes in the brain that are related to
schizophrenia."
Muñoz
didn't deign to answer Mosher's letter of
resignation. However, it came to the attention of
Psychology Today's editor, who asked Mosher
if he would summarize his position for the
magazine. In the September/October 1999 issue,
Mosher's contribution ran under the splashy
headline, "Are Psychiatrists Betraying Their
Patients?" Alongside it, the magazine ran four
"responses." A spokesman for the National Alliance
for the Mentally Ill pointed out that "some
individuals with brain disorders such as
schizophrenia and bipolar disorder may at times,
due to their illness, lack insight or good judgment
about their need for medical treatment." But
"involuntary treatment of any kind should be used
only as a last resort."
The
director of the National Institute of Mental Health
harrumphed, "It would be tragic if Dr. Mosher's
personal history prevented anyone with mental
illness from obtaining effective treatment." He
declared that a treatment revolution had occurred
"in the years since Mosher has been active in
research.… In place of medications with
questionable efficacy and major negative side
effects, or unproven and expensive psychotherapies,
we now have a variety of safe and effective
medications and psychotherapies for mental
illnesses."
A
spokesman for the American Psychiatric Association
conceded that Mosher's fears about the commercial
influence on medication education were "an issue of
great concern for all of medicine." However, the
American Psychiatric Association had "instituted a
careful review and monitoring process, ensuring
that sessions supported by the pharmaceutical
industry at our meetings present solid scientific
information in an unbiased manner."
By
far the longest rebuttal to Mosher's essay was the
one written by Frederick K. Goodwin, a Washington,
D.C., psychiatrist with weighty credentials. A
former director of the National Institute of Mental
Health, Goodwin today is a professor of psychiatry
at the George Washington University Medical Center,
as well as director of its Center on Neuroscience,
Medical Progress, and Society. He also hosts a
radio program called The Infinite Mind that
airs on 200 Public Radio stations throughout the
country. Contacted by phone, Goodwin agreed to
discuss his prickly response in Psychology
Today. "I knew Loren many years ago when he was
at NIMH, and he was always way outside the
mainstream." According to Goodwin, Mosher believed
that psychiatry was simply used for political and
social control. "That was actually a legitimate
position in the '60s," Goodwin asserted, explaining
that biological psychiatry was just getting started
at that time. "There wasn't a lot of evidence, so
it was still an open debate." A psychiatrist named
Thomas Szasz had written a book called The Myth
of Mental Illness that was "very influential,"
according to Goodwin. "Szasz had come from Hungary
under the Soviet Union, and there his position
probably had some reality to it. Later on, we found
out that the Soviet Union did use
psychiatry for social control."
Goodwin
contended that Mosher continued to be fixated on
ideological issues. "What really gets a man like
Loren Mosher upset is coerced treatment," he
stated. "He's very aligned with a group called the
Psychiatric Survivors, who are largely people who
when you talk to them still have their paranoid
processes going on. And they feel that somebody
shouldn't have medications forced on them." The
problem, Goodwin suggested, is "that one of the
critical symptoms of these serious illnesses --
both bipolar illness and schizophrenia -- is loss
of insight. Every psychiatrist has horror stories
of patients who were let go from an involuntary
hospitalization to go on to either kill themselves
or wreck their lives." The assumption "on Mosher's
side," Goodwin continued, "is that when a person
refuses treatment, they're doing it with the same
capacity to make judgments as you and I would. They
refuse to see that the very organ of judgment, the
organ of insight, is itself diseased. So what do
you do when a person's psychosis tells him that
he's going to be poisoned by this
medication?"
"Virtually
the entire field was upset by that Psychology
Today piece, including the editor of
Psychology Today," Goodwin asserted. Parents of
schizophrenics who saw it also had reason to be
outraged, Goodwin suggested. "These are people who
live with these patients and love them and are
desperately frightened that there's not going to be
enough help for them when they die. They don't have
any ideological battle to defend. All they know is
how sick their kids are when they don't take their
medication. They must think these arguments about
whether this is a real illness or not are quite
silly."
In
his published response to Mosher's essay, Goodwin
also attacked Mosher's Soteria research, stating,
"Incidentally, Mosher's 1970s 'study' purporting to
compare 'meaningful relationships' with medication
was no such thing. A true scientific inquiry would
have required a single pool of patients randomly
assigned to either psychotherapy or drug groups."
When pressed for further details about this charge,
Goodwin said that his statement "was really a kind
of throwaway line." He stressed that he wrote the
response at the request of the Psychology Today
editor on just three days' notice, "and I first
said no because I wouldn't have time to really
research it carefully." He said what he meant was
that "in this kind of study people had to agree to
go into one group or the other. And [Mosher and
his colleagues] didn't really report how many
people didn't want to be assigned to the no-drug
group or the no-hospital group. So it's hard to
know whether the less-sick patients opted to go
into the Soteria House and the sicker ones and
their families and their doctors wanted to be in
the hospital. So that's not truly random." (Mosher
retorts that patients in the study did not choose
where they were treated. "The two groups were
absolutely comparable.")
"I'm
not saying that that kind of environment can't help
people," Goodwin hastened to add. "There are some
people who can get really psychotic with a little
bit of vulnerability under tremendous stress. And
then with a lot of support, they can pull out of it
on their own. As a clinician, I would never
question that. The question is, Is this
generalizable? And did his experience with Soteria
House give him the right to say that everyone else
is ignorant, or they're just trapped by the drug
companies' money, or they're Nazis who really want
to control people?"
"Fundamentally,"
Goodwin said, "the argument is, Are these real
illnesses? Do they involve biology? Are these brain
diseases or not? And this is a battle that should
have been over years ago. When [Mosher]
says in his letter that there's no evidence that
these are brain diseases, that's just pure
ignorance."
Goodwin's
area of expertise is bipolar disease (also known as
manic depression). But he suggested that any number
of prominent schizophrenia specialists could
discuss the mountain of evidence demonstrating that
schizophrenia is an organic illness. One whom he
recommended was Dr. Daniel Weinberger, chief of the
clinical brain disorders branch of the Intramural
Research Program at the National Institute of
Mental Health. Contacted by e-mail, Weinberger
responded, "There are many, many pieces of evidence
that Schizophrenia is a disease.… There is no
ONE preeminent thing. There is an accumulation of
compelling SCIENTIFIC evidence, objectively
ascertained and subjected to the scientific method
of disproof. The statements of [Mosher] are
personal biases, likely motivated by a desire to be
heard, not to help people with these terrible
illnesses."
Another
schizophrenia expert praised by Goodwin was Dr.
Nancy Andreasen. Head of the psychiatry department
at the University of Iowa College of Medicine,
Andreasen also is editor of the American
Journal of Psychiatry, and she herself conducts
neuropsychiatric research. Asked (again, in an
e-mail) about Mosher's contention that
schizophrenia is not a medical disease, Andreasen
suggested that Mosher lacks "any kind of scientific
track record, as indicated by peer-reviewed
publications."
For
an overview of the supporting evidence that
schizophrenia is a brain-based disease, Andreasen
offered a chapter in her book, Brave New
Brain, published by Oxford University Press
last year. In the section that addresses the
question of what causes schizophrenia, Andreasen
begins by making one unequivocal assertion. It "is
not a disease that parents cause," she declares.
"In most cases several causes have conspired to
injure the developing brain and mind, but bad
parenting is not one of them."
The
earliest evidence of the biological basis of
schizophrenia came from genetic studies, Andreasen
writes, and it began with the "simple observation
that mental illnesses sometimes run in families."
She acknowledges that this might mean certain
families do things that drive their children crazy,
but she says the transmission pattern instead
suggests a genetic role. "If one parent has
schizophrenia, there is about a 10% chance that one
of their children will develop schizophrenia. If
both parents have schizophrenia, then this risk
increases substantially to about 40 or 50%.
Likewise, chances for developing schizophrenia if
one brother or sister has the illness are about
10%, and these increase to about 20% if one parent
and one brother or sister is ill with
schizophrenia."
Studies
of twins provide additional evidence. Andreasen
says more than ten studies involving hundreds of
twin pairs have consistently shown that identical
twins (who share almost exactly the same genes)
both have schizophrenia far more often than
nonidentical twins (who share only about half of
their genes) -- about 40 percent of the time
compared to only 10 percent.
Although
she sees this as "clear evidence that genes must
play a role," she points out that genetic factors
cannot be the only cause. If they were, the
concordance rate for identical twins would approach
100 percent, not four out of ten. Moreover, no
single gene for schizophrenia has been found. "Most
experts now think that schizophrenia is clearly
multifactorial, involving multiple genes, and
possibly even different genes in different
individuals, as well as many nongenetic or
environmental influences," Andreasen
writes.
A
number of environmental influences occurring early
in life have fallen under suspicion, according to
Andreasen. She says researchers have found a higher
rate of schizophrenia among people who had
traumatic births, as well as among those whose
mothers were malnourished during their pregnancies
or gave birth during influenza epidemics or in the
wintertime ("a season during which mother and child
are more often exposed to a variety of viral
influences"). Brain MRI scans, however, provide
"perhaps the strongest evidence" that schizophrenia
occurs because something interrupts the orderly
development of the brain from conception through
adolescence, Andreasen contends. She says about 5
percent of schizophrenic males have been shown to
have something called ectopic gray matter, "tiny
islands of neuronal cells that did not make it to
their proper destination…during the second
trimester of pregnancy." This rate is higher than
that seen in normal healthy individuals. Another 20
percent of schizophrenic males also seem to have a
small gap between the two hemispheres of their
brains (whereas fewer nonschizophrenic adults have
such a gap).
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