Virtually across the board of medicine and psychiatry, doctors will constantly and consistently oversell the benefits of a given treatment, and undersell the risks and side effects of it. This may not be as surprising when you look at some of the key factors into how medical and psychiatric treatment is learned and then conducted on patients.
Why do doctors often oversell the benefits of a given treatment, and minimize the risks and side effects of it?
1. Treatment is rarely experienced first-hand.
While you don’t need to undergo surgery to understand the benefits of surgery or how to do surgery, you will surely have a great appreciation to the patient’s perspective if every surgeon was required to get an appendectomy before being allowed to practice. Surgeons know, in most cases only hypothetically, what it is like to go under the scalpel. I wonder how much differently a surgeon might practice if that were no longer the case.
In the same vein, I wonder how many psychiatrists would continue to prescribe atypical antipsychotics or electroconvulsive therapy (ECT) if they themselves tried it a few times. That’s because we treat fixing human problems the same way we treat fixing a car or dish disposal — it’s just plumbing and organic connections.
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Good topic – I have came to similar conclusions through my own experience.
As for #4, however, I do NOT think that it’s always the best to be “brutally honest”, because expectations of pain can increase experienced pain. A doctor can’t be too much off, but low-balling expected pain a little bit could be a good idea.
As for #5 – true and shows why voluntary choice of treatment is SO important. Drugs help those who believe in them, therapy helps those who believe in it, homeopathy helps those who believe in it – so on and so forth. It might “stop working” – then a new treatment is to be selected – by the person who will experience it.
Brilliant post. I just got into a discussion with an MD about this yesterday since this issue does have a huge impact on general trust of the field of psychiatry in general. This particular MD has done research on uncovering negative studies that were not published in order not to reflect badly on drugs, so that does bring up an additional factor since if side effects are being underreported then doctors may not even have accurate information on what the risks are.
Dr Grohol, I apprediate your excellent article and I believe it addresses a topic that is rarely addresses and has become increasely more dangerous for patients who are suffering some form of mental distress.
I would like to limit my discusion toward the two subjects I am familiar with, the treatment of severe Climical Depression and Bipolar Disorder with Psycothropic Meds.
While this article posits an excellent question a better one would be: Why do doctors accept statistical results in psychotropic drug testing as evidence of efficacy?
In testing for anti-depressive drugs a college study obtained, with an FOIA filing to the FDA, test results that showed six drugs had 47 tests to get the 12, two per drug, positive test results required to be able to sell them.
Never the less these drugs are promoted and given as safe and effective.
Why would any doctor do that?
It’s not only doctors who have the idea “drilled into them” that there’s a solution for every problem. We patients also have an expectation (or at least a fervent desire) that something can be done to relieve each and every form of physical pain and suffering.
Even if there’s no effective medical treatment known for a particular condition, there’s still almost always the possibility of human contact and compassion, i.e. “bedside manner.” But… not everybody’s talented, or comfortable, or trained, to do that. The patient may not want to “just talk”. And insurance usually won’t pay (much) for it. Thus, there’s an overwhelming incentive to offer a technological solution, in almost every situation.
Dr Grohol, as a soon-to-be graduating psychiatrist, I have been reading and appreciating your blog for a number of years. I especially appreciated your articles about the false dichotomy between psychiatry and psychology (http://psychcentral.com/blog/archives/2010/01/14/the-false-dichotomy-psychiatry-versus-psychology/) and your conclusions about whether psychiatry is a science (http://psychcentral.com/blog/archives/2010/03/14/is-psychiatry-a-science/).
Your rational arguments and reluctance to get involved in denigrating other mental health professionals is what sets you apart from other writers. In short, I find you to be very well balanced.
It came as a surprise to me when this latest blog posting showed up in my inbox. I found it to be grossly overgeneralized and unhelpful. It does not make sense to me how on the one hand you comment on the ‘breathtaking amounts’ and ‘methodologically sound’ research done in psychiatry in your previous blog posts, but then accuse psychiatrists of ‘nearly random trial-and-error practice’. My patients cannot help but be confused when they see someone extolling the virtues of psychiatric research but then tearing that down by accusing practitioners of ‘flying-by-the-seat’ of their pants.
Furthermore, you accuse psychiatrists (and virutally the entire medical profession) of routinely overstating the benefits and underselling the risks of (presumably) medication or other invasive treatments. This is true of poor practitioners, but it is certainly unfair to label every single one of us as a lying caricature like Gregory House MD. To be frank, the vast repository of knowledge found on the internet keeps all of us honest. Patients can and do look up all the side effects of any treatment and routinely present these to us before we even make suggestions. There is no opportunity to downplay the risks— patients are more informed than ever before, and I ENCOURAGE them to do their own searching to confirm what I tell them.
The criticisms leveled at the medical profession can be fairly and equally assigned to ALL mental health professionals, including psychotherapists. I often see patients who have undergone psychotherapy with experienced, well credentialed therapists who have failed to see any benefit from their therapy. These patients were lead to believe that psychotherapy would be very beneficial, and have few if any adverse effects. They were disappointed when their symptoms continued, and surprised when they sometimes ended up feeling worse. I encounter many of these patients on hospital wards and in emergency rooms after suicide attempts. It is clear to me that SOME psychotherapists oversell benefits and undersell risks, just as SOME doctors do.
There is no need to generalize and demonize a particular profession. We all want the best for our patients. Certainly this leads to weaknesses at times, especially when we are limited to one particular type of treatment (eg. psychotherapy vs pharmacotherapy). You have acknowledged yourself that both are often needed. I have been privileged in Canada to receive very comprehensive training in both psychotherapy and pharmacotherapy so that I am hopefully less susceptible to the bias that arises from being limited to one modality. Furthermore, our healthcare system reimburses me fairly equally whether I choose to treat someone with medication or talk therapy. (This is probably better discussed separately).
I will end by quoting some of your own words from one of my favorite articles. “We don’t need this ongoing proselytizing in the blogosphere that’s shared by many academics, researchers and evangelists in their respective professions. It’s time to put aside our professional differences, and reach across the aisle to ensure that individuals in need get the best possible care, no matter what it may be.” I could not have said it better myself.
When you re sitting in your chair across the desk from a desperate patient/parent, you to will reach for the “newest” drug that just walked into your office by way of legalized drug pusher called a pharmaceutical rep. With a brillant smile, nice suit they will confidently tell you all about the two test trails that prove this drug is the savior, the drug of drugs(you busy filling out countless forms of HMO’s, PPO’s Other forms, trying to fit your annuul learning credits (which you will most likely take from a pharmaceutical company as they will be fre or best buy with lots of freebie thrown in). Psychiatry is a random based and trail and err based medicine practice. Ask any patient. Ask any practicing Psychiatrist who is willing to be open about how many medicines and combinations of medications it takes to find the right balance, not just to band-aid the symptoms, but also give the patient a quality of life.
Absolutley true that a person will not trust a Dr who lies. Nor will I personaly allow any Dr to treat me unless they will first listen to me and not treat me condensingly just becouse I hav’nt a MD. I may not have an MD, but I DO KNOW HOW certain cllasses of pills have affected me. I am the the one who has to deal with the side effects. Recently a Dr decided that it was in my best interest to put me on a anti-depesant, without telling me. Yes I should have looked the drug up before taking it, that’s a sad commentary when a patient has to double check medicines. So even not knowing I was taking a antidepreant, I was hospitalized twice-those Dr’s did bother to tell me I was on an anti-depresant either. Lost a lot of friends, and my volunteer jobs. So much for that Dr wanting to HELP me! I am now off everything, not wiling to trust a shrink again, not with my life. Doing far better with omega3, yoga and eating right. I’m not trusting any shrink again, I call them legalized pill pushers. I think it is great a Dr wrote about the outcomes of Drs who just write scripts. Not only do they need to feel the side effects of pills themselfs but they also need to be hospitalized(covertly), and not listened to, before they can be allowed to treat anyone.
Hi M —
Well said.
I didn’t mean to single out the medical profession, but in hindsight, I see I did exactly that. Indeed, any health professional — psychologists included — can oversell the benefits of their treatment. I’ve seen psychologists do this in everything from psychotherapy and biofeedback, to reiki and relaxation therapy.
This entry was motivated by a personal experience that happened to someone close to me, and so is more biased than my usual self. I was so sickened by her story, it motivated me to write this entry and do so in a way that likely painted too broad a swath and used terms like “most professionals” instead of “some professionals.”
My apologies.
Dr Grohol:
I applaud you for bringing up this “taboo” topic. I have been a patient that was not receiving an effective psych med. When I was not improving to the med or therapy, the doc responded with either upping the dose or change/add another med. I was on multiply meds and the side effects, showed as a mental illness so I started with depression and then was hit with addition codes from the DSM. I was fortunate to meet up with a doc that actually listened to me about how the drugs were making me feel. I also changed to a new therapist. The result some 4 years later is that I am now happiest I have been in 10 years.
Doctors who actively engage the patient in the care plan are in the minority of the profession.
Just a quick note of appreciation for Dr. Grohol:
I’m continually amazed how you consistently post articles like this one, critical of your own profession, all the while refraining from cynicism, maintaining balance, offering constructive suggestions, acknowledging your biases (like in your response to M’s comment), AND presenting it all in the form of high quality writing.
Thanks for doing what you do!
You know, “wanting to help”, “fixing” the patient, as well as “understating the side affects” is one thing. BUT, it is a complete other to have a doctor or therapist be informed of side affects and they write them off and make you feel “crazy” for reporting them.
First, one thing you didn’t mention was GP’s prescribing Antidepressants. You wouldn’t go to a GP to have your cancer treated. You wouldn’t have a dentist set a broken are for you. BUT, we readily let GP’s prescribe antidepressants? Why the mental health industry hasn’t stood up for the right to solely be the ones to prescribe them is beyond me.
At the point that doctors are neglecting and ignoring FDA protocol, innocent feelings of desire to help becomes malice. How often is a test for bipolar conducted before a GP prescribes Zoloft, Prozac, Effexor, or any of the SSRI/ SNRI as required via the pamphlet. Likewise, how often do GP’s or therapist keep in “close contact with patients family and caregivers” as cited in every AD’s prescribing pamphlet.
As my ex entered a complete and total state of mania with every one of the symptoms (including arrest for violence) they refused to believe it. Her GP’s response, upped the dose of Prozac and prescribed birth control to deal with the “new found sexual freedom”. This with in 3 months of starting. Never a brush with the law, never had asked for BC in the 5 yr relationship with the doc. This was the answer.
Then we won’t even get into the pharmaceuticals twisting of words by calling things “discontinuation syndrome” but not “withdraw syndrome”.
Your article makes it sound much more innocent then what I have experienced.
Thanks for your reply to my comment, Dr. Grohol. I realize that you were simply advocating honesty and empathy, both of which are often lacking in our profession. All of us ‘professionals’ would do well to adhere to advice given by one of my wisest professors who told me “when in doubt about what is the right thing to do for your patient, simply be more human”. I think you showed your humanity in this blog post and your response. For that, there is no need to apologize.
I have, too many times, felt like and been treated as a lab rat. Some psychiatrists just throw medicine at you and hope something sticks. They don’t know which chemicals you are missing or have too little of. They don’t know if you need one med or a combination of meds. The truth is they “Just Don’t Know”. And that is the problem of all medical professions. You only become proficient in treating someone through trial and error. Hopefully some day, psychiatry will grow past it’s “infant” stages and treatment will be more informed and more precise.
I am a psychiatrist who takes Zoloft. I also have taken Topamax and Abilify. These don’t make me feel any worse than Oral Contraceptives, Inderal or Doxycycline.
Every day I see people suffering from psychosis, often terrified of various people and organizations that they perceive to be persecuting them. For many of them, antipsychotics calm the delusions which cause them terror. Some of my patients suffering from true Bipolar I Disorder have spent thousands of dollars they didn’t have, and lost jobs, in the throes of mania – for them, mood stabilizers or atypical antipsychotics decrease the risk of extreme upheaval.
I do agree that it is ineffective to medicate mild situational sadness or anxiety, and risks can easily outweigh benefits. However, many of my patients make an informed decision otherwise. This is our modern American culture – fast food, plastic surgery and cosmetic psychopharmacology. I tell people that antidepressants won’t help situational sadness or anxiety (and describe the risks), and recommend counseling instead, but in 9 years I have yet to see one patient choose counseling, except half-heartedly as an adjunct. SSRIs and the newer antidepressants, I will often prescribe, with informed consent, a thorough history, some lab work and no contraindications. Most other psychotropics, especially benzodiazepines, I am much more strict about.
I am blessed to have a job where I serve persons with the most severe Axis I pathology (generally psychoses), so medicines can help. I suspect that people seen by counselors and psychotherapists are probably generally healthier than those seen by psychiatrists.
The article is informative and helpful. The key for me is that I believe these practitioners are well meaning, professional and do intend to heal. That said, we need to look at the pharmaceutical companies and the tricks with generics, side effects and incomplete research data pushed upon the public via the national commercial audience. Would one ever consider asking for a particular chemo drug after watching it from a television commercial? It’s a campaign directed from the pharma companies and R & D, I’m convinced, that has us wanting SSRI’s after that McDonald’s ad. Don’t blame the Dr.’s. I’ve found you have to take their advice and use your own common sense in your own treatment.
I feel very lucky to have a psychiatrist who is open to my opinions, informs me of side effects, elicits information she needs, and prescribes appropriate medications to address my needs.