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Back when I was growing up in the early 1960s, there was a popular song out by Bobby Vee, called “Devil or Angel”. I believe it contained lyrics along the lines of, “Dear, whichever you are, I need you.” The title of the song might also be a good summation of the way psychotropic drugs are portrayed in the popular press and other media. And, sad to say, even some of my colleagues in the mental health profession fall into one of two armed camps, when it comes to the role of medications for mood and behavior. This dichotomy parallels the schism described in Tanya Luhrmann’s influential study of psychiatry, aptly entitled, Of Two Minds. Very roughly, Luhrmann argued that the field of psychiatry is still divided between those who see mental illness as a psychological problem amenable to psychosocial therapies; and those who see it as a problem of abnormal brain chemistry, best treated by pharmacotherapy. Despite many attempts to bridge this conceptual chasm — Dr. George Engel’s “biopsychosocial model” is one example — the schism persists to this day.
And this is truly a shame. The “Angel or Devil” dichotomy does nobody any favors, and certainly does not help patients with serious emotional disturbances. In truth, the human brain is the crucible in which all the elements of our experience and sensation are transformed into thought, feeling, and action. We can affect the function and structure of the brain directly, by altering its chemical constituents; or we can affect its function and structure indirectly, by pouring helpful words into the ear of the patient. Speech, music, poetry, art, and a myriad of other “inputs” are all transduced into neuronal connections and electrochemical processes in the brain.
This does not mean that we ought to greet our patients by asking, “How are your serotonin molecules this morning, Mrs. Jones?” Part of our shared behavior as human beings is the use of language that speaks to our felt experience, not our neurons. But this does not mean that our experience is ultimately something over and above the workings of our brains. Moreover, far from being “cosmetic” in nature, many psychotropic medications work at the most fundamental level of the gene, actually increasing the production of nerve growth factors.
These are all reasons why we should not dismiss psychotropic medications out of hand. They are neither agents of the devil, as some extremist factions argue; nor are they angels of redemption, as one might conclude from the “rainbow and butterfly” ads put out by some pharmaceutical companies. Psychotropic medications, as I tell my patients, are neither a crutch nor a magic wand; they are a bridge between feeling bad and feeling better. The patient must still walk — sometimes painfully — across that bridge. This means doing the hard work of changing thoughts, feelings, and behaviors. Medications can often aid that process, and are sometimes needed to get the patient’s work in therapy moving. For example, some patients with very severe depression are so lethargic and cognitively impaired that they can’t fully engage in psychotherapy. After three or four weeks of antidepressant treatment, many of them are able to benefit from “talk therapy”, which then may provide long-term protection against depressive relapse. Some evidence suggests that initial antidepressant treatment can help “set up” the patient for subsequent long-term psychotherapy. As a recent review by Dr. Timothy J. Petersen [1] concluded,
“…sequential use of psychotherapy after induction of remission with acute antidepressant drug therapy may confer a better long-term prognosis in terms of preventing relapse or recurrence and, for some patients, may be a viable alternative to maintenance medication therapy.”
Other evidence indicates that talk therapy and medication work synergistically — one reinforcing the other. Medications may help more with “somatic” aspects of depression, such as impaired sleep and appetite; psychotherapy, more with cognitive aspects, such as guilt or hopelessness. Evidence from brain imaging studies suggest that each intervention may work through overlapping but somewhat different mechanisms: antidepressant medication seems to work “from the bottom up”, arousing lower brain centers associated with emotion. Psychotherapy appears to work from “the top down” by changing neural patterns in higher brain centers, such as the prefrontal cortex.
Given the huge literature on psychotropic medications, I am focusing on antidepressants in this essay — a diverse group of agents that has been the focus of tremendous controversy. In recent years, for example, questions have been raised regarding both the efficacy and safety of antidepressants. There is a voluminous literature on these topics, but here is my best professional synopsis. Antidepressants seem to “show their stuff” more robustly in cases of severe depression, but this may be partly an artifact of how most studies are designed and analyzed. For example, the most recent review from Kirsch and colleagues [2] suggests that in mild-to-moderate depression, antidepressants do not work better than a sugar pill (placebo). In very severe depression, Kirsch et al found, the newer antidepressants outperform placebo, though their benefits are not as robust as in earlier studies (1960s-70s) of the “old” tricyclic antidepressants.
However, we need to put these recent findings in perspective. Numerous posts on the internet have declared, based on the Kirsch et al study, that “Antidepressants Don’t Work!” But this is not what the study showed. Rather, it lumped together results from 47 antidepressant trials and found that the active drug showed a clinically significant “separation” from placebo only in the most severe cases of depression. This is actually much better than finding that antidepressants work only for very mild depression! That said, the Kirsch study attributed the apparent benefit of antidepressants in the most severely ill patients to reduced responsiveness to placebo rather than to increased effectiveness of the drug.
There are a number of problems with the Kirsch study, many of which are nicely discussed in Dr. Grohol’s recent blog (2/26/08) on this website. For one thing, the entire Kirsch study turns on whether a 2-point improvement in a single depression rating scale (the Hamilton Rating Scale for Depression, or HAM-D) amounts to a “clinically significant” (not just statistically significant) change. That is, of course, a matter of judgment. Second, the Kirsch study looked only at antidepressant trials in the FDA data base done prior to 1999; an analysis of more recent trials might have produced different results. Third, the kind of “number crunching” that goes on in any meta-analysis (basically, a study of studies) can obscure not only individual differences, but also subgroup differences. That is, a given patient with certain depressive symptoms—or a subgroup with certain features—may do quite well on an antidepressant, but the results are “submerged” in the overall mediocre success rate in the study as a whole.
There are many other reasons why studies of antidepressants may be yielding less than spectacular results in more recent decades, and the interested reader can find details in an editorial by Kobak and colleagues, in the February 2007 Journal of Clinical Psychopharmacology. These authors point out, among other things, that if the interviews producing HAM-D depression scores are not performed skillfully, the results of the study may be distorted. Kobak and colleagues pointed to several instances in which poor interviewing technique led to outcomes showing little difference between the antidepressant and placebo; conversely, good interviewing technique led to a more robust improvement rate (“effect size”) for the antidepressant. It is not clear how many such “junk interview” studies were included in the Kirsch et al meta-analysis.
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14 Responses to “Devil or Angel? The Role of Psychotropics Put In Perspective” (Pingbacks/trackbacks not shown below)
Karl at 10:56 am on
March 3rd, 2008
Great writeup!
Thank you so much. I have been following all the coverage from the recent study you cited. Your essay is informative and practical. I think we have to remind ourselves that managed care has contributed to the “medicate first.” When I was first diagnosed, my doctor and therapist could only get me 48 hours in the hospital and 10 clinical visits. My therapist argued my case, saying “We can’t even get her stabilized in 48 hours!” We all agreed to keep me out of the hospital and they gave me 20 more visits. I went to therapy twice week. When my visits were up, I used up my savings to get the help. Thankfully, I am on a better plan now. But what do people who don’t have insurance do? Are we to belittle them for not going to therapy when they can’t afford it? The meds do work and for some people it is all they have.
ron pies at 5:33 pm on
March 3rd, 2008
Thanks to both Karl and Lizzie for their comments. I appreciate both, and fully agree with Lizzie that the non-insured or under-insured face daunting barriers to effective care. Of course, I strongly believe anyone treated with an antidepressant should also be involved in some kind of “talk therapy”, and that this should be covered by their insurance policy! –Best regards, Ron Pies MD
Kent at 12:10 am on
March 5th, 2008
Yes, both psychosocial therapies and psychotropic drugs have done some good for some people, but the drugs pose a danger that talking therapies could never match. It’s not as easy to convince policymakers that someone can be changed for the better by forcing them to undergo psychosocial therapy, and noone ever developed diabetes or Parkinson’s Disease as a side effect of talk therapy. Back when psychiatry was mostly associated with talk therapy, there was a joke that asked how many psychiatrists it took to change a lightbulb - the answer being “just one, but only if the lightbulb really wants to change.” Nowadays, many mental health professionals no longer concern themselves with whether or not someone wants to change before accepting them for treatment, and the faith given to medications is part of the reason why. So while I don’t disagree that both kinds of treatment can be used for good, I believe the drug-based treatment has a unmatched potential for evil which cannot be ignored. To just compare these two types of treatment based on their potential effectiveness without considering their potentials for harm seems totally amoral to me.
Ronald Pies MD at 1:25 am on
March 5th, 2008
Thanks, Kent, for your comments. You raise an important issue: the potential harm that can come from treatment of any kind–”talk therapy” or medication. Indeed, my article did not discuss comparative risks, and it is a valid question to raise.
Unfortunately, in my view, your argument is based on a popular fallacy–and one that experienced psychotherapists recognize as a myth; namely, the notion that psychotherapy or “talk therapy” cannot do significant harm. Having seen both the good and the bad done in psychotherapy over my 25 years of practice, I can assure you that, in the wrong hands, “talk therapy” can do incalculable harm. There is ample evidence, for example, that inexperienced or unskilled therapists trying to treat trauma victims can make matters much worse. In their book, “Essentials of Child and Adolescent Psychiatry”, Drs. Mina Dulcan and Jerry Wiener write that, “…poorly-conducted therapy at best can be a waste of precious time in the life of a child, and at worst can be harmful and…inadvertently lead to re-traumatization.” (p. 492). There is also ample evidence in the literature that poorly-run “encounter groups” or group therapy can lead to psychotic reactions in some vulnerable group members [see B. Kufferle, Psychopathology. 1988;21(2-3):111-5.]. Let’s leave aside the thorny and controversial issues of “false memory syndrome” and sexual exploitation of patients by psychotherapists. There is still plenty of risk involved, even in ethically-conducted psychotherapy.
Yes, it is probably true, as you say, that no one ever developed diabetes or parkinsonian symptoms as a result of “talk therapy”–but you have not convinced me that diabetes or tremor (due, say, to an antipsychotic medication)represents a greater “evil” than re-traumatizing a rape victim or inducing psychosis in a patient with schizophrenia. In most cases of drug-related side effects, we can reduce the medication dose, change to a different drug, or counteract the side effect. But once you have re-traumatized a victim of rape or other violence, it is very, very hard to “reverse” that.
The fact is, Kent, there are no treatments that I know of, in psychiatry or in general medicine, that have absolutely no potential to do harm, and yet are also “powerful” and effective. From antibiotics to cancer chemotherapy agents, physicians are always aware that their interventions have the potential to both heal and harm. I have never met an experienced and knowledgeable psychotherapist who was not also aware of the risks that “talk therapy” presents.
That said, I have seen the tremendous good that psychotherapy can accomplish, as I have with proper use of psychotropic medication. Indeed, since you raise the issue of “morality”: it would be morally irresponsible, in my view, for any physician or therapist to rule out either medication of psychotherapy, in cases where one or both would likely benefit the patient. –Yours truly, Ronald Pies MD
Flips at 10:56 am on
March 5th, 2008
Wow! I could actually understand this article. Good synthesis and writing!
Hello from Brazil at 1:13 pm on
March 5th, 2008
Congratulations for such a clear article. After years of struggling fighting depression, I couldn´t agree more. Combo talk + medication therapy has aided me tremendously.
In Brazil, not even medication can be deducted from Health plans. Depression is still heavily “moralized” as Krammer describes ( the concept) in his book, as a negative mental handicap. Here we struggle to have this right assured or recognized.
America is teaching us that mental issues are no different than heart issues. I hope one day we will reach that point of justice and non-discrimination.
Kent at 3:38 pm on
March 5th, 2008
Thanks for your thoughtful response, Dr. Pies. I didn’t really mean to imply that talk or psychosocial therapies have no potential for harm. Almost anything anyone does in life has some potential for harm - just walking across a street can be risky. But psychiatric medications are so ubiquitous in the United States nowadays and so uncritically accepted that I think their negative effects are more widely felt than are those of most other kinds of treatment.
One of the worst characteristics of these medications seems to be that so much faith is vested in them, because of the aura of scientific certainty surrounding them, that it is considered legitimate to force people to take these drugs whether they want to or not. I suppose it’s also possible that people are occasionally forced into talk-based therapies as well, but I think the futility of that kind of forced treatment is much more apparent - when someone forced into that kind of therapy doesn’t talk, even the therapists are likely to become frustrated and speak out against imposing it on anyone who doesn’t want it.
I am familiar with “false memory syndrome” and most of the other kinds of harm you describe that can be associated with psychosocial therapies, and I don’t believe those kinds of therapies should be forced on the unwilling anymore than I believe that drug-based therapies should. The thing is, though, I think it’s probably much less common to have governments passing laws to force large numbers of people to undergo talk therapies, so it’s much more likely that people taking the risks of that kind of treatment had some say in whether or not they thought the risk was worth the potential benefits for them.
In regards to general medicine, I think it’s almost unheard of as a matter of public policy to force something like antibiotics or cancer treatments on people who explicitly object to receiving them. I believe it’s generally better for people in positions of power to avoid doing harm to people than it is for them to not neglect any potentially beneficial course of action, and that it is generally a much greater immorality to force potentially damaging treatments on someone than it is to withhold a treatment - unless it is something that the person definitely wants, in addition to being potentially beneficial.
Ron Pies at 8:57 pm on
March 5th, 2008
from Ron Pies MD
Thanks to “Flips” and to “Hello from Brazil”. I appreciate your comments. Re: “Hello”, it sounds like mental health care in Brazil might be even harder to come by than in the U.S. This is a shame. Count me among those who advocate universal health care, and “parity” for psychiatric disorders (i.e., reimbursed equally with so-called “medical” disorders, though I don’t like the distinction!).
Kent, thanks for your response. I think we are largely in agreement on the matter of “risk”. Both psychotropic medication and “talk therapy” carry both contingent and inherent risks. Contingent risks have to do with the particular patient, type of drug or psychotherapy, training of the practitioner, etc. Inherent risks are those that are always possible, no matter how skilled the clinician, how carefully the patient is monitored, etc. Of course, competent patients (or their appointed guardians) should always be carefully informed of both the contingent and inherent risks of any health-related treatment, whether psychotherapy, medication, surgery, etc.
Your other points regarding involuntary administration of medication, Kent, are much more complex and difficult to address in a short space. The issues you raise go far beyond the scope and intent of my original article. As you know, civil libertarians, psychiatrists, and ethicists have debated the issue of involuntary treatment for at least the past fifty years. And, you are correct in noting that psychotropic medications have special issues surrounding their use, which are rarely encountered in the treatment of, say, cancer or infectious disease.
As a general point of philosophical orientation, I will start by saying that, like most psychiatrists, I am opposed to any “forced” use of medication or any other treatments, under what I would call “ordinary circumstances”. And, of course, all physicians are pledged to “do no harm” when treating their patients.
Unfortunately, ethical dilemmas arise when the “ordinary circumstances” of treatment (i.e., a rational patient and a physician mutually agree to establish a therapeutic relationship) do not apply. For example, a patient with paranoid schizophrenia and command auditory hallucinations telling him, “Kill the students in the classroom!” refuses to take any antipsychotic medication or to obtain other professional treatment. (Obviously, I have in mind recent tragic events in the news).
No psychiatrist or other physician likes being in the situation of enforcing compliance with medication in such a situation, Kent; and, indeed, it is ultimately up to a judge to decide if such treatment is warranted. Judges must carefully weigh the risks and benefits to the patient, as well as the risks and benefits to society at large, in such a decision. If society does not want to involve psychiatrists or other physicians in such deliberations, then the laws that govern these proceedings will have to be changed by our legislators. (By the way, I do not want to over-emphasize the issue of “dangerousness” in those with mental illness–for more on that, see my piece in the 2/25/08 Boston Globe:
http://www.boston.com/news/health/articles
/2008/02/25/mentally_ill_unfairly_portrayed
_as_violent/).
You are right, Kent, that is almost “unheard of” to force treatment with antibiotics or cancer drugs. That’s because most patients with infections or cancer are both mentally competent to make medical decisions in their own behalf; and are not an immediate danger to themselves or others. Unfortunately, those qualities may not apply to a minority of those with serious mental illness, such as schizophrenia or bipolar disorder. But please note: I said, “a minority”.
It is actually a very small percentage of individuals with mental illness in the U.S. who are taking medication involuntarily; for example, under some kind of court order. And whenever possible, we try our best to convince such seriously-ill people to take the medication voluntarily. Again, these questions are ultimately settled not by doctors, but by judges, and patients are entitled to benefit of counsel, due process of law, etc.
With respect to whether “talk therapy” may also be “forced” under certain unusual circumstances, the answer is, “yes”, at times. For example, a judge may order a person with alcohol abuse and a “DUI” (driving under the influence) conviction to attend a “12-step” program, such as AA, or some type of counseling–even if the person does not want the treatment.[see
http://alcoholism.about.com/od/dui/a/mandatory.htm
Even in other areas of medicine, society does sometimes enforce “treatment” against a person’s wishes. For example, with the recent upsurge in tuberculosis, some patients refuse to get treatment or restrict their exposure to the general public. For such persons, involuntary observed treatment and/or quarantine have been permitted under the law (see Booker MJ. Compliance, coercion, and compassion: moral dimensions of the return of tuberculosis. J Med Humanit. 1996 Summer;17(2):91-102). As Prof. Mark Rothstein has put it in his lecture, “Public health must balance individual and group interests, autonomy and paternalism, and individual liberty and public well being.” [www2a.cdc.gov/phlp/docs/Rothstein020101.ppt].
Well, all this is far afield from my original article, but I hope it allays some of your concerns, Kent. My piece on “Devil or Angel” was really just aimed at reminding people that
we should not “demonize” any type of treatment, and that both medication and “talk therapy” have important roles in helping those with serious emotional disorders. Cheers…RP
Kent at 11:52 pm on
March 5th, 2008
One last thing I’d like to mention regarding psychiatric drugs and violence: their effect on violent behavior isn’t always to make it less likely. Sometimes they may actually make it more likely, especially when someone is first starting to take a particular drug, or trying to withdraw from it, as described in this news release:
http://www.mindfreedom.org/shield/psychrights
It might be in society’s own best self-interest to consider this possibility when thinking about forcing any of these drugs on anyone.
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Great writeup!
Thank you so much. I have been following all the coverage from the recent study you cited. Your essay is informative and practical. I think we have to remind ourselves that managed care has contributed to the “medicate first.” When I was first diagnosed, my doctor and therapist could only get me 48 hours in the hospital and 10 clinical visits. My therapist argued my case, saying “We can’t even get her stabilized in 48 hours!” We all agreed to keep me out of the hospital and they gave me 20 more visits. I went to therapy twice week. When my visits were up, I used up my savings to get the help. Thankfully, I am on a better plan now. But what do people who don’t have insurance do? Are we to belittle them for not going to therapy when they can’t afford it? The meds do work and for some people it is all they have.
Thanks to both Karl and Lizzie for their comments. I appreciate both, and fully agree with Lizzie that the non-insured or under-insured face daunting barriers to effective care. Of course, I strongly believe anyone treated with an antidepressant should also be involved in some kind of “talk therapy”, and that this should be covered by their insurance policy! –Best regards, Ron Pies MD
Yes, both psychosocial therapies and psychotropic drugs have done some good for some people, but the drugs pose a danger that talking therapies could never match. It’s not as easy to convince policymakers that someone can be changed for the better by forcing them to undergo psychosocial therapy, and noone ever developed diabetes or Parkinson’s Disease as a side effect of talk therapy. Back when psychiatry was mostly associated with talk therapy, there was a joke that asked how many psychiatrists it took to change a lightbulb - the answer being “just one, but only if the lightbulb really wants to change.” Nowadays, many mental health professionals no longer concern themselves with whether or not someone wants to change before accepting them for treatment, and the faith given to medications is part of the reason why. So while I don’t disagree that both kinds of treatment can be used for good, I believe the drug-based treatment has a unmatched potential for evil which cannot be ignored. To just compare these two types of treatment based on their potential effectiveness without considering their potentials for harm seems totally amoral to me.
Thanks, Kent, for your comments. You raise an important issue: the potential harm that can come from treatment of any kind–”talk therapy” or medication. Indeed, my article did not discuss comparative risks, and it is a valid question to raise.
Unfortunately, in my view, your argument is based on a popular fallacy–and one that experienced psychotherapists recognize as a myth; namely, the notion that psychotherapy or “talk therapy” cannot do significant harm. Having seen both the good and the bad done in psychotherapy over my 25 years of practice, I can assure you that, in the wrong hands, “talk therapy” can do incalculable harm. There is ample evidence, for example, that inexperienced or unskilled therapists trying to treat trauma victims can make matters much worse. In their book, “Essentials of Child and Adolescent Psychiatry”, Drs. Mina Dulcan and Jerry Wiener write that, “…poorly-conducted therapy at best can be a waste of precious time in the life of a child, and at worst can be harmful and…inadvertently lead to re-traumatization.” (p. 492). There is also ample evidence in the literature that poorly-run “encounter groups” or group therapy can lead to psychotic reactions in some vulnerable group members [see B. Kufferle, Psychopathology. 1988;21(2-3):111-5.]. Let’s leave aside the thorny and controversial issues of “false memory syndrome” and sexual exploitation of patients by psychotherapists. There is still plenty of risk involved, even in ethically-conducted psychotherapy.
Yes, it is probably true, as you say, that no one ever developed diabetes or parkinsonian symptoms as a result of “talk therapy”–but you have not convinced me that diabetes or tremor (due, say, to an antipsychotic medication)represents a greater “evil” than re-traumatizing a rape victim or inducing psychosis in a patient with schizophrenia. In most cases of drug-related side effects, we can reduce the medication dose, change to a different drug, or counteract the side effect. But once you have re-traumatized a victim of rape or other violence, it is very, very hard to “reverse” that.
The fact is, Kent, there are no treatments that I know of, in psychiatry or in general medicine, that have absolutely no potential to do harm, and yet are also “powerful” and effective. From antibiotics to cancer chemotherapy agents, physicians are always aware that their interventions have the potential to both heal and harm. I have never met an experienced and knowledgeable psychotherapist who was not also aware of the risks that “talk therapy” presents.
That said, I have seen the tremendous good that psychotherapy can accomplish, as I have with proper use of psychotropic medication. Indeed, since you raise the issue of “morality”: it would be morally irresponsible, in my view, for any physician or therapist to rule out either medication of psychotherapy, in cases where one or both would likely benefit the patient. –Yours truly, Ronald Pies MD
Wow! I could actually understand this article. Good synthesis and writing!
Congratulations for such a clear article. After years of struggling fighting depression, I couldn´t agree more. Combo talk + medication therapy has aided me tremendously.
In Brazil, not even medication can be deducted from Health plans. Depression is still heavily “moralized” as Krammer describes ( the concept) in his book, as a negative mental handicap. Here we struggle to have this right assured or recognized.
America is teaching us that mental issues are no different than heart issues. I hope one day we will reach that point of justice and non-discrimination.
Thanks for your thoughtful response, Dr. Pies. I didn’t really mean to imply that talk or psychosocial therapies have no potential for harm. Almost anything anyone does in life has some potential for harm - just walking across a street can be risky. But psychiatric medications are so ubiquitous in the United States nowadays and so uncritically accepted that I think their negative effects are more widely felt than are those of most other kinds of treatment.
One of the worst characteristics of these medications seems to be that so much faith is vested in them, because of the aura of scientific certainty surrounding them, that it is considered legitimate to force people to take these drugs whether they want to or not. I suppose it’s also possible that people are occasionally forced into talk-based therapies as well, but I think the futility of that kind of forced treatment is much more apparent - when someone forced into that kind of therapy doesn’t talk, even the therapists are likely to become frustrated and speak out against imposing it on anyone who doesn’t want it.
I am familiar with “false memory syndrome” and most of the other kinds of harm you describe that can be associated with psychosocial therapies, and I don’t believe those kinds of therapies should be forced on the unwilling anymore than I believe that drug-based therapies should. The thing is, though, I think it’s probably much less common to have governments passing laws to force large numbers of people to undergo talk therapies, so it’s much more likely that people taking the risks of that kind of treatment had some say in whether or not they thought the risk was worth the potential benefits for them.
In regards to general medicine, I think it’s almost unheard of as a matter of public policy to force something like antibiotics or cancer treatments on people who explicitly object to receiving them. I believe it’s generally better for people in positions of power to avoid doing harm to people than it is for them to not neglect any potentially beneficial course of action, and that it is generally a much greater immorality to force potentially damaging treatments on someone than it is to withhold a treatment - unless it is something that the person definitely wants, in addition to being potentially beneficial.
from Ron Pies MD
Thanks to “Flips” and to “Hello from Brazil”. I appreciate your comments. Re: “Hello”, it sounds like mental health care in Brazil might be even harder to come by than in the U.S. This is a shame. Count me among those who advocate universal health care, and “parity” for psychiatric disorders (i.e., reimbursed equally with so-called “medical” disorders, though I don’t like the distinction!).
Kent, thanks for your response. I think we are largely in agreement on the matter of “risk”. Both psychotropic medication and “talk therapy” carry both contingent and inherent risks. Contingent risks have to do with the particular patient, type of drug or psychotherapy, training of the practitioner, etc. Inherent risks are those that are always possible, no matter how skilled the clinician, how carefully the patient is monitored, etc. Of course, competent patients (or their appointed guardians) should always be carefully informed of both the contingent and inherent risks of any health-related treatment, whether psychotherapy, medication, surgery, etc.
Your other points regarding involuntary administration of medication, Kent, are much more complex and difficult to address in a short space. The issues you raise go far beyond the scope and intent of my original article. As you know, civil libertarians, psychiatrists, and ethicists have debated the issue of involuntary treatment for at least the past fifty years. And, you are correct in noting that psychotropic medications have special issues surrounding their use, which are rarely encountered in the treatment of, say, cancer or infectious disease.
As a general point of philosophical orientation, I will start by saying that, like most psychiatrists, I am opposed to any “forced” use of medication or any other treatments, under what I would call “ordinary circumstances”. And, of course, all physicians are pledged to “do no harm” when treating their patients.
Unfortunately, ethical dilemmas arise when the “ordinary circumstances” of treatment (i.e., a rational patient and a physician mutually agree to establish a therapeutic relationship) do not apply. For example, a patient with paranoid schizophrenia and command auditory hallucinations telling him, “Kill the students in the classroom!” refuses to take any antipsychotic medication or to obtain other professional treatment. (Obviously, I have in mind recent tragic events in the news).
No psychiatrist or other physician likes being in the situation of enforcing compliance with medication in such a situation, Kent; and, indeed, it is ultimately up to a judge to decide if such treatment is warranted. Judges must carefully weigh the risks and benefits to the patient, as well as the risks and benefits to society at large, in such a decision. If society does not want to involve psychiatrists or other physicians in such deliberations, then the laws that govern these proceedings will have to be changed by our legislators. (By the way, I do not want to over-emphasize the issue of “dangerousness” in those with mental illness–for more on that, see my piece in the 2/25/08 Boston Globe:
http://www.boston.com/news/health/articles
/2008/02/25/mentally_ill_unfairly_portrayed
_as_violent/).
You are right, Kent, that is almost “unheard of” to force treatment with antibiotics or cancer drugs. That’s because most patients with infections or cancer are both mentally competent to make medical decisions in their own behalf; and are not an immediate danger to themselves or others. Unfortunately, those qualities may not apply to a minority of those with serious mental illness, such as schizophrenia or bipolar disorder. But please note: I said, “a minority”.
It is actually a very small percentage of individuals with mental illness in the U.S. who are taking medication involuntarily; for example, under some kind of court order. And whenever possible, we try our best to convince such seriously-ill people to take the medication voluntarily. Again, these questions are ultimately settled not by doctors, but by judges, and patients are entitled to benefit of counsel, due process of law, etc.
With respect to whether “talk therapy” may also be “forced” under certain unusual circumstances, the answer is, “yes”, at times. For example, a judge may order a person with alcohol abuse and a “DUI” (driving under the influence) conviction to attend a “12-step” program, such as AA, or some type of counseling–even if the person does not want the treatment.[see
http://alcoholism.about.com/od/dui/a/mandatory.htm
Even in other areas of medicine, society does sometimes enforce “treatment” against a person’s wishes. For example, with the recent upsurge in tuberculosis, some patients refuse to get treatment or restrict their exposure to the general public. For such persons, involuntary observed treatment and/or quarantine have been permitted under the law (see Booker MJ. Compliance, coercion, and compassion: moral dimensions of the return of tuberculosis. J Med Humanit. 1996 Summer;17(2):91-102). As Prof. Mark Rothstein has put it in his lecture, “Public health must balance individual and group interests, autonomy and paternalism, and individual liberty and public well being.” [www2a.cdc.gov/phlp/docs/Rothstein020101.ppt].
Well, all this is far afield from my original article, but I hope it allays some of your concerns, Kent. My piece on “Devil or Angel” was really just aimed at reminding people that
we should not “demonize” any type of treatment, and that both medication and “talk therapy” have important roles in helping those with serious emotional disorders. Cheers…RP
One last thing I’d like to mention regarding psychiatric drugs and violence: their effect on violent behavior isn’t always to make it less likely. Sometimes they may actually make it more likely, especially when someone is first starting to take a particular drug, or trying to withdraw from it, as described in this news release:
http://www.mindfreedom.org/shield/psychrights
It might be in society’s own best self-interest to consider this possibility when thinking about forcing any of these drugs on anyone.
