Look, i don’t want to start looking like I am ‘borderline’, and sound like I am idealizing you, and before you know it, I will start commenting about how everything you write is garbage. So, i am reluctant to say once again that this article is great, not to mention your comments to Kent and which are way beyond great.

I am glad you discussed this research that claims antidepressants work no better than placebos, because to me, there is something not quite right about this. In fact, i do not believe it for a second. (Although, the way you talk about it puts a little sense to the story)

I mean, I know myself very well, both my body and my mind, and states of mind, and my history, and experiences, and all that put together, and I trust myself quite a bit.

And, no way would I not know the difference between a placebo and the real thing. Prozac is powerful stuff, and when it works, it works. Even after having taking it for way more years than it has been approved in this county, I can still tell the difference. (I also believe that I will have to take it forever since it has changed my brain chemistry but that is another story)

But when I have periods where I feel myself going downhill, I increase my usual dose (40 mg) by 20mg, and immediately i feel the difference. I usually only do this for maybe 3 or four days and that’s all it takes.

I also really thought my mother would so much benefit from an antidepressant when she turned around 80, and she woke up every morning around four just worrying and worrying. She didn’t want to but then she gave in, and this has made such a huge positive difference in her life. I tend to think antidepressants should be much more prescribed for old people anyway. (maybe then my father would not have killed himself at the age of 88, and after he really had lived a great life but….well, whatever)

There is just no way, and i don’t get it with these placebo being equal results.

Anyway, this article and your comments were really interesting for me, and great. Best, Katrin (not edited, again. Back to bed)

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.

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 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.

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.