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July 12, 2019 by Bob Nikkel, MSW

System Change Toward a Green Movement in Mental Health

One morning a few weeks ago, I woke up thinking maybe we should begin to think of reforms in mental health systems as a kind of “green movement” with some striking similarities to the other greens: the green environment, a green economy, green energy, and so on.

The upcoming Mad in America Continuing Education series intends to use that as a framework for the ten webinars we will launch soon. More on that in a bit, but first, some quick background is in order.

An early leader of the Modern Green Movement was Rachel Carson, whose book Silent Spring (1962) laid out the dangers of detrimental effects to the environment caused by the indiscriminate use of pesticides.

She made accusations against the chemical industry of spreading disinformation and public officials of accepting these claims. These accusations could just as easily be applied to the cozy relationships between the pharmaceutical industry and the major psychiatric organizations as documented in Robert Whitaker and Lisa Cosgrove’s Psychiatry Under the Influence (2015).

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June 28, 2019 by Sandra Steingard, MD

A Guide to Long-Acting Neuroleptics: Education or Promotion?

Several weeks ago, I received a number of emails notifying me of a new pamphlet released by the National Council for Behavioral Health titled “Guide to Long-Acting Medications for Providers and Organizations.”

The pamphlet begins:

“This Guide to Long-acting Medications (LAMs) is a Call to Action for psychiatrists, other clinicians and behavioral health organizations to increase the use of LAMs.” It goes on to suggest that psychiatrists and their organizations (which comprise the membership of the National Council) rally resources to make these drugs more readily available as “first-line treatment.”

The authors opine upon “What Science Tells Us,” namely, that “there is enough science to demonstrate the degradational effects on brain tissue of each psychotic episode.” Moreover, we are informed that — when started early — the neuroleptic drugs will “avert progressive neurodegeneration and subsequent disability.”

The pamphlet is designed as a public health promotion with this message: If we can stop the progression of schizophrenia, we will improve long-term outcomes. This is purported to be based on science.

I would argue that if one follows the science, one might support instances in which long-acting drugs are useful but not necessarily to the extent suggested in this pamphlet. In addition, one would not promote the newer drugs as first-line treatments.

By downplaying some aspects of the available science, the pamphlet implicitly is acting as a promotional tool for the pharmaceutical industry. Furthermore, this pamphlet serves as an example of why simple disclosures of conflict do not adequately address deeper issues of bias and influence in our field.

While the authors correctly state that this was not funded by pharmaceutical companies, it is nevertheless influenced by their interests via the incursion of commercial interests into academia over the past few decades.

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June 28, 2019 by Foundation for Excellence in Mental Health Care

Holistic Options for ADHD Treatment

‘Micronutrients for ADHD Youth’ Study Now Enrolling Participants


Attention Deficit Hyperactivity Disorder (ADHD) is the presence of the behaviors of hyperactivity, impulsivity, and poor attention. The root causes and best solutions for these troubling behaviors will vary from child to child.

Parents concerned about the safety and effectiveness of popular drug treatments can try some promising alternatives with a significantly lower risk of unwanted side effects. Many have found psychotherapy and parent training highly effective in resolving troubling behavior and improving their child’s social skills and relationships with peers.

For some, micronutrient supplements have been life-changing:

The Micronutrients for ADHD Youth study is now accepting new participants, with sites at Oregon Health & Science University, The Ohio State University in Columbus, and University of Lethbridge in Alberta, Canada. Eligible children are age 6-12 and have not been on ADHD medications for two weeks before their participation begins.

Contact lead researcher, Jeanette Johnstone, PhD, at  503-494-3700 or healthykids@ohsu.edu if you are within driving distance of Portland, Oregon.

If you are near Columbus, OH, contact E. Arnold, MD at OSUMC-maddystudy@osu.edu

If you are near Lethbridge, Alberta, contact B. Leung, PhD at healthykids@uleth.edu

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June 1, 2019 by Bob Nikkel, MSW

Public purse a cash cow for pharma

Could billions in taxpayer dollars for psych drugs be better spent?

A few years ago when I was directing a Medicaid mental health managed care organization, the irascible senator from Iowa, Chuck Grassley, got a burr under his saddle, as they say in the Midwest, about what the federal government was paying out for psychiatric medications in Medicaid expenditures.  And he was able to connect the cost information to individual prescribers.

The two highest prescribing billers were in my area in Oregon.  I was shocked for several reasons.

The first was that I had no idea what these figures were because they weren’t in my Medicaid budget.  The second was that the highest prescriber was in my area.  In one year alone, he had billed $457,000 of psychiatric medications, mostly Abilify.  The third—and this was an extremely dismaying shocker—was that he was a child psychiatrist, and so he had been prescribing Abilify and these other drugs to children and adolescents.

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May 3, 2019 by Bob Nikkel, MSW

Ten Lessons for Mental Health System Change

For the past several years, my blogs have centered on a topic that is admittedly not the most exciting – how policy can affect practice, especially in public mental health systems.  Distilling my 50 years of experience with a combination of direct work with people, management positions within local and state organizations and nearly 6 years as a state mental health and addictions commissioner, I think I learned a number of lessons about system changes.  But I haven’t taken a deeper dive into strategies, especially focused for advocates who seek significant and even radical changes – until now.
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March 14, 2019 by Bob Nikkel, MSW

Two Upcoming Webinars in Our Informed Consent Series

We have two outstanding webinars of great clinical relevance and interest coming up on the Mad in America Continuing Education Project.

Registrations are open at: education.madinamerica.com/p/what-would-real-informed-consent-on-drugs-look-like

On March 19, Dr. Sandy Steingard will talk about what informed consent can and should look like in a real life community mental health program. Dr. Steingard has been a leader in this country and is getting increasing attention elsewhere for her courageous and research-based approach to psychiatry. She is particularly well-prepared to discuss issues related to the use of psychiatric medications. You can see notice of her webinar here along with the learning objectives she will be addressing.

We are asking for a registration fee of $75 but it covers all 6 of the webinars in this series. You can contact me if you want to discuss an organizational rate or discuss a scholarship option.

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March 12, 2019 by Bob Nikkel, MSW

National Basketball and Peer Supports

I see eye-to-eye with most players in the National Basketball Association.  Recently I proved this by a random meeting with two guys in the Portland airport who were just a shade taller than I am–one was a former NBA player and the other a current member of the Portland Trailblazers.  6-10 and 6-11, respectively.

So you are asking, what does this NBA stuff have to do with peer support?
Adam Silver, the commissioner of the NBA was interviewed recently and talked about the number of NBA players, who in spite of their athletic success–and I might add, their million dollar plus contracts–deal with a lot of unhappiness in their personal lives.
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February 8, 2019 by Alita Kathryn Taylor, MA, LMFT

Love Is In the Air…

I am in love.  I’m in love with this way of working.  And I won’t stop.  Open Dialogue Washington began in 2018 upon my graduation/commencement from Jaakko Seikkula’s dialogic approaches to couple and family therapy trainer/supervisor training, in collaboration with Dialogic Partners and the University of Jyväskylä.

In 2016, I embarked to partake in the best training course I had ever experienced as a family therapist.  The embodiment I experienced working with my Open Dialogue colleagues felt like the missing key in psychiatry and psychotherapy.  Something intangible, yet what I knew all along.  Something ineffable, yet also a shared language.  Something deeply and autonomically human, yet unrepeatable and fleeting.   It led me onto a moment-by-moment path where everything I learned in my 27-year long career about systemic family therapy and emergency psychiatric protocols ebbed, and the present moment of love flowed, neither the ebbing knowledge nor the cresting wisdom having any lesser value than the other.  The complete work we do in mental health care is this ocean of love.

We are in constant change when we are in crisis.   Timelessness sets in.  Growth is happening.  We don’t exactly know what we need.  That is what mental health work is, sitting with this human happening.  In the in-between space something happens, and we don’t know what will.  This is the paradox.  We are navigating the ebb and flow of incoming knowledge we have from research and the ebb and flow in each patient and family’s difficulties (the meanings they make of them.)

“It cannot be taught, but it needs a teacher.”

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January 21, 2019 by Craig Wagner

The Good, the Bad, and the Ugly: An Infographic on Bipolar Drugs

This post helps make sense of the mountain of bipolar drug research. It distills into an infographic the pros and cons of five classes of bipolar drugs and gives observations on what it means for people who face choices on bipolar care.

Although this post wanders deeply into the statistical weeds, we avoid technical jargon. To maintain statistical rigor, we use technical definitions for important phrases below. [1]

(The infographic is kept fresh as research evolves. The latest version with footnotes is always here.)

A few key perspectives behind this infographic deserve attention:

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January 14, 2019 by Sandra Steingard, MD

Open Dialogue: Does the Current Research Data Support Further Investment?

Psychiatric Services, a leading US journal, has published two important papers on Open Dialogue. Freeman and colleagues did an extensive literature review and analysis of currently available research. Their paper is accompanied by a commentary by Kim Mueser, PhD, Director of the Boston University Center for Psychiatric Rehabilitation and one of the world’s experts in his field.

Freeman and colleagues begin their paper with a detailed explanation of the criteria for inclusion into their investigation. They identified 23 studies for review. Papers selected were published in English and evaluated Open Dialogue effectiveness using either case study, qualitative, quantitative, or mixed methods. Studies were conducted in Finland, Norway, Sweden, and the US.

As the authors point out, most of the available research comes from the Western Lapland group that developed Open Dialogue (OD). This poses a fundamental source of weakness in the evidence base. Their studies had small sample sizes, there was no control group, and the ratings were not blinded. In addition, there were not consistent methods for either defining or evaluating OD.

Many of us learned of Open Dialogue because of their reported excellent outcomes for individuals who experienced a first episode of psychosis. We are eager to see if these results can be replicated elsewhere. But there are other important questions.

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