Dear Mrs. ——–
You have asked me about the cause of your mood disorder, and whether it is due to a “chemical imbalance”. The only honest answer I can give you is, “I don’t know”—but I’ll try to explain what psychiatrists do and don’t know about the causes of so-called mental illness, and why the term “chemical imbalance” is simplistic and a bit misleading.
By the way, I don’t like the term “mental disorder”, because it makes it seem as if there’s a huge distinction between the mind and the body—and most psychiatrists don’t see it that way. I wrote about this recently, and used the term “brain-mind” to describe the unity of mind and body.1 So, for lack of a better term, I’ll just refer to “psychiatric illnesses.”
Now, this notion of the “chemical imbalance” has been much in the news lately, and a lot of misinformation has been written about it—including by some doctors who ought to know better 2. In the article I referenced, I argued that “…the “chemical imbalance” notion was always a kind of urban legend—never a theory seriously propounded by well-informed psychiatrists.”1 Some readers felt I was trying to “re-write history”, and I can understand their reaction—but I stand by my statement.
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Good morning, Dr. Pies. I enjoyed reading this post, but currently I am very troubled by the situation of a family memebr who is rapid-cycling Bipolar, under the care of a psychiatrist, and who has been in inpatient substance abuse treatment twice in the last 8 years. He is NEVER offered any type of talk therapy for his Bipolar; the psychiatrists not only do not offer this, they do not refer. It is just ongoing Seroquel. Why do psychiatrists shun talk therapy?
This was very timely — thank you. It’s a good starting point for discussion with my bipolar friends (heck, anyone with a mental illness diagnosis).
Thanks very much for the comments and questions so far, which I will address soon. Just so readers will not be disappointed or put off: I have a standing policy of directly addressing only writers who use their full names. I know that isn’t comfortable for some readers, and I will try to address non-signed questions in a general way. Thanks for your understanding, and I look forward to a good discussion!–Ronald Pies MD
I’ve read this article twice now and am finding it difficult to take on board.
On one hand Ronald Pies MD states that there is no chemical imbalance yet, on the other hand, he claims psychiatric illnesses probably involve abnormalities in specific brain chemicals.
So these ‘abnormalities’ would be a chemical imbalance, right?
I have to say, it’s refreshing to see an Ronald Pies MD agree that there is no such thing as a chemical imbalance but utterly confusing to see that a psychiatric illness is apparently caused by the same chemical imbalance that Ronald Pies MD debunked in his opening statement?
On the subject of abnormalities in specific brain chemicals. Are there any blood tests that can be taken to prove this or is it just another theory?
Bob Fiddaman – Author of ‘The evidence, however, is clear…the Seroxat scandal.
Right on Doc. I kept waiting to hear the lines I have heard over and over again, “there is nothing we can do. We have to treat chemical imbalances with these drugs.” I loved the candor with which you spoke of you fellow mental health cohorts. What you didn’t note was that most poorly diagnosed BPD patients are first given their SSRI after a 5 min visit with they GP.
Twins not only have a biological connection, BUT they also have an even more profound attribute relative to their psychological makeup. They have the same nurture environment. It would take a few hundred twins at birth (which would come with its own psychological hazards) and watch as they are raised in environments known to contribute to manic and depressive episodes, anxiety, and OCD. Separated parents is one of those factors known as far back as the late 80’s. This was noted in the book “I hate you, Don’t leave me: Understanding the borderline personality”. Likewise, my assertion is that we don’t know how to define “good parenting” in this country before we can decide if it cause mood driven dysfunctions. We live in a country where 51% marriages end in divorce (many bitterly), an insane amount of single mothers, and from birth out TV’s pound us with fear driven messages. At 8 weeks a mother is expected to get back to work. The child is dropped off at daycare. Fathers feel that they put 40 hours in at work, they “deserve” to come home and plop on the couch on Sunday and ignore their kids. Of the relationships that are together, most have problems”.
While in this post I applaud your nod to “the scientific method”. You let the ball slip when you tied biology to psychology. We can not now that with certainty. To date, using the scientific method, no gene has ever been determined to be a cause of any of the “security mental dysfunctions” (I believe I made that term up). The only thing we can know is that whether it biology or psychology, there is a 40% chance of the other twin conducting themselves with a bipolar pathology. That is enough to apply preventative techniques.
As far as not using my name. I have learned that using my name can be used to take my young impressionable child away from my custody and give her to an SSRI driven manic who threatened to kill the child and herself. Simply because I tried to share my story so others my be better informed. So now I uses a more apt name.
I really appreciate this enlightening read. My friend is going through a really emotional time,and just deciding if he’s going to seek help. I’m definitely going to send this for him to read.
“My impression is that most psychiatrists who use this expression feel uncomfortable and a little embarrassed when they do so. It’s a kind of bumper-sticker phrase that saves time, and allows the physician to write out that prescription while feeling that the patient has been “educated.” If you are thinking that this is a little lazy on the doctor’s part, you are right. But to be fair, remember that the doctor is often scrambling to see those other twenty depressed patients in her waiting room. I’m not offering this as an excuse–just an observation.”
Respectfully, I disagree. I think you write this paragraph to excuse it as an editor of a widely read publication by both psychiatrists and other clinicians interested in psychiatric literature, that relies significantly on pharmaceutical funding in advertisements, and just attempt to minimize the damage this attitude and ongoing behaviors by a sizeable percentage of our colleagues is doing to our patients. If you really do not agree with it, then criticize it outwardly and honestly, and truly be a leader, not a follower.
I see patients EVERY DAY who say without provocation on my part how the prior clinician, be it psychiatrist, family practitioner, primary care physician, nurse practitioner, or other clinician with the ability to access a precription pad, basically describe a visit or repeated visits that are just about almost shoving prescriptions across a table after sometimes just 2 minutes of alleged discussion.
Isn’t that type of revelation not just outrageous to hear, but is almost negligent in acting as a provider?
But then again, I do not expect you to agree, as we have had similar discussions in the past. No, let’s be honest, and I would hope Dr Grohol will allow this comment to shine a light on our ongoing dispute: it is about your opinion and avoidance of any honest dispute. But, the readers who are truly unbiased and objective will figure out what is genuine concern and advocacy for the public we take an oath to protect, and, who is just doing damage control.
I stand by my opinion as backed by my career as a practicing psychiatrist in many domains of mental health care these past 18 years. Because I do not practice politics first, which has been a detriment to me at times, but, at least at the end of the day, I know I did my best to do what is the standard of care for the way I was trained.
As with any mood disorder, it’s caused by being around white or black people. These people irritate the shit outta you causing you to have a change in mood and wanting to kill them or beat them up severely. I dont blame u for feeling like this because these people are stupid idiots and deserve that sort of treatment.
Maybe Dr Pies can find the time to read this link, digest it, and comment if necessary.
http://www.baltimoresun.com/health/boostershots/la-heb-treatment-depression-20110804,0,512893.story
Personally, while the article makes a good point that many primary care physicians find it hard to access a psychiatrist for a timely referral, which really is an indictment of our field in the end, 4 of 5 antidepressant prescriptions are written by non psychiatrists this past decade or longer is a damning statistic.
Why this is occurring? In my opinion, hear the lie enough and it becomes truth. Biochemical imbalance fits the somatic model oh so conveniently. Yeah, if only mental health problems were as simple as strept throat or hypercholesterolemia. Oh, maybe the latter of those two examples is not so cut and dry either!
Just don’t ask that of those who profit off Lipitor!!!
To those who have submitted comments or questions, I very much appreciate your time
and effort. Most of you have raised excellent points and stuck to the issues, rather than
casting aspersions.Thank you!
I would first like to address the point of confusion raised by Mr. Fiddaman, who
wonders how, on the one hand, I can debunk the “chemical imbalance” theory; and on the
other hand, assert that psychiatric illnesses probably involve abnormalities in specific
brain chemicals. Aren’t these claims contradictory? The answer, Mr. Fiddaman, is no, but I can see why my point was confusing.
To be precise, I wrote that, “The most we can say is that, in general, certain psychiatric illnesses probably involve abnormalities in specific brain chemicals…” My claim is actually quite different than the one I am attacking; namely, that “a brain-based, chemical imbalance causes mental illness’ [see my reference 4].How so?
Here is an analogy. Consider these two claims: 1. Certain changes in the global climate probably involve abnormally high levels of carbon dioxide. 2. Global climate change is caused by abnormally high levels of carbon dioxide. The first statement is tentative(“probably”); applies only to “certain” changes; and uses the word “involves”.
The second claim is a categorical, blanket statement that uses the word “caused.” In
scientific terms, these claims are not at all the same.
Here is another analogy. We know that when people are suddenly frightened, say by a large snake, we can soon measure high levels of adrenaline in their blood (part of the “fight or flight” response). And so, it’s fair to say that adrenaline is “involved” in the fear response. But that doesn’t mean that adrenaline causes fear. More likely, our brain first registers “Dangerous snake!” We then experience fear, and our adrenal glands start pumping out adrenaline.
So, too, when we analyze psychiatric
illnesses (“mental disorders”). Re: blood tests–I could quote you a dozen different
studies showing that the hormone cortisol is “involved” in episodes of melancholic major
depression (the really severe, “industrial strength” version of the illness).And, yes, we
can measure elevated cortisol levels in the blood of many melancholic patients (more so than in controls). But that doesn’t mean that melancholic major depression is necessarily, or in all cases,
caused by elevated blood levels of cortisol.
As Dr. Grohol indicates in his essay, “Mental disorders are not simply brain diseases.”
http://psychcentral.com/blog/archives/2011/07/24/mental-illness-is-not-simply-a-
brain-disease/] They are complex “bio-psycho-social” conditions that affect persons, not just brains. And their causes are various and legion. We can’t understand psychiatric illnesses without understanding the brain; but neither can we
understand them without deep knowledge of the person who has the illness.
On a related issue: Dr. Hassman rightly calls attention to an article in the Baltimore Sun, which discusses the recent work of Drs. Ramin Mojtabai and Mark Olfson[see HEALTH AFFAIRS 30,NO. 8 (2011)]. The study found that,
“Over the past two decades, the use of antidepressant medications has grown to the point that they are now the third most commonly prescribed class of medications in the United States. Much of this growth has been driven by a substantial increase in antidepressant prescriptions by nonpsychiatrist providers without an accompanying psychiatric diagnosis.”
This is indeed a worrisome finding and raises troubling questions: why are so few
psychiatrists (percentage-wise) involved in prescribing these medications?(About 80% of these prescriptions are written by primary care physicians). Are patients who get antidepressants from PCPs receiving an adequate evaluation and
an accurate diagnosis?
My own view is that evaluation in primary care is often cursory, and the diagnosis often missed or mistaken. (As one reader correctly notes, bipolar
disorder is often mistakenly diagnosed as “depression” and inappropriately treated). At the same time, as Mojtabai & Olfson are careful to point out, “These results do not clearly indicate a rise in inappropriate antidepressant use.” It may be that some PCPs are prescribing antidepressants for what, in some cases, would not meet the full DSM criteria for a psychiatric
diagnosis, but which may still be a debilitating condition.
And, it is very important to note that Mojtabai and Olfson do not see the problem simply as a crisis of “over-prescription”. Rather, it is a crisis of treatment “misalignment”. They write that,
“…paradoxically, a large proportion of patients with common mental disorders do not
receive needed treatment because their primary care providers do not detect their conditions. The widening misalignment between diagnosis and treatment suggests the need for a deeper inquiry.”
Of course, it is lamentable when doctors pull out the old “chemical imbalance” card in explaining an antidepressant prescription to a patient. But we do no good by simply affixing the scarlet letter to these doctors. We need to understand what leads them to use this strategy, and help them see that there are better ways of caring for their patients.
No, psychiatrists have not given up on psychotherapy–60% still provide it for at
least some of their patients [see http://psychcentral.com/blog/archives/2011/04/03/has-psychiatry-really-abandoned-psychotherapy-the-story-behind-the-new-york-times-story/. But we need to create a health care system that encourages psychiatrists to provide talk therapy more frequently, and which allows patients affordable access to both medication and psychotherapy.
Ronald Pies MD
Doc,
Thanks again for your candor and insight. The question of “Why (I think there is humor and irony in calling them PCP’s) GP’s insist upon pushing pills?” is a combination of social, financial, and even egotistical. On the doctors side, they leave school with a 1/4 million dollar school loan and that needs paid for. What better way then to get patients hooked on a drug that requires them to keep coming back. Many believe themselves on some subconscious level to be “gods” above other people. All their schooling they went through and they save lives.
On that patients side, we westerners, especially Americans are lazy. We want our weightless in a pill, any pain that pelages us in a pill, physical health in a pill, and our happiness in a pill. If we can’t take a pill for it, we need to be able to cut it out. Thus prior to AD’s there was lobotomies. It is a hard road to dig into ones repressed memories and confront our “Id’s”. I describe it often as “you have to reach into your soul and rip your demons out, caste them on the ground, and command ‘you will not control me any longer!’” The amount of pain, discomfort, frustration to get to that demon is overwhelming at times. It can take months and often years to get to that point. Then at the end you may find the answer are worse then you ever imagined. Having to admit family members were especially abusive or dysfunctional for example. We also can’t take blame or place blame on those we love. Something outside our control has to be causing our problems. Genes, chemicals, environment are likely excuses.
For talk therapy this can amount to thousands if not 10′s of thousand of dollars along with the pain. OR take this pill, it won’t take your problems away, but it will make you not care about them. The side affects are that you will also stop caring about anything. Your spouse, your children, your career, your own well being. Small price to pay for “happiness”. It “fixes your chemical imbalance”.
“So, too, when we analyze psychiatric
illnesses (“mental disorders”). Re: blood tests–I could quote you a dozen different
studies showing that the hormone cortisol is “involved” in episodes of melancholic major
depression (the really severe, “industrial strength” version of the illness).And, yes, we
can measure elevated cortisol levels in the blood of many melancholic patients (more so than in controls). But that doesn’t mean that melancholic major depression is necessarily, or in all cases,
caused by elevated blood levels of cortisol.”
I am confused again Ronald.
In essence, and forgive me for being presumptuous, you just don’t know, do you?
It’s basically based on theory, yet the drugs used to treat such disorders are taken as remedies to control these disorders – there is no cure, I’m sure we can agree on that?
If disorders of the brain could be diagnosed via blood samples then why is this practice not used in doctors/psychiatrists surgeries?
What I find irksome is the need for the pharmaceutical industry to defend their magic potions when things go wrong. We have an admittance by them that, in the case of SSRi’s, they may cause suicidal ideation. Yet every single time someone comes forward to make a claim that an SSRi prompted a family member to take their own life, the pharmaceutical company, who manufactured that particular SSRi, deny their drug had anything to do with the patient killing themselves. Nine times out of ten their defence will be that the ‘patient was suffering depression’ – a good argument but one that does not validate the use of these drugs in the first place.
SSRi’s were first promoted as correcting a chemical imbalance – many doctor’s still believe they do. It would be beneficial if those pharmaceutical companies made a statement about their original promotion taglines but we all know that the business of depression is big bucks.
The SSRi market is slowly grinding to a halt, no newer drugs seem to be in the pipeline – the MD choice seems to be swinging toward drugs such a Risperdal etc, many of which are prescribed “off-label” to children who haven’t yet developed fully functional brains.
Parenting skills, poor diets and sleep habits need to be looked at before any mind altering drug is given to a child…maybe blood samples that show a child as “ADHD” could be offered to prove psychiatry is correct and children are not just being children.
Thank you for your in-depth reply but it still leaves more questions than answers.
Bob Fiddaman
Author of The evidence, however, is clear…the Seroxat scandal.
If I had a dollar for every time I had a psychiatrist say I had a “chemical imbalance” “just like diabetes,” requiring “meds for the rest of my life.”
Probably 3 of the most common phrases psych patients hear.
Dr Ronald Pies admits that many psychiatrists are at a loss to understand the causes of mood disorders, probably in an attempt to justify the poor success rate of treatment by way of drugs and/or talk therapy.
Perhaps those psychiatrists should have a look at the tremendous amount of research and work done by Nutritional Doctors who have been able to help many people with depression overcome their mood disorders without resort to drugs and even without talk therapy:
Depression is a Nutritional Disorder at:
http://www.hypoglycemia.asn.au/articles/depression_disorder.html
I appreciate the comments and questions, though many go considerably beyond the scope and intent of my article. It was not my aim to defend antidepressants or medications for ADHD–though when carefully prescribed and monitored, both can
be safe and effective. Neither was my intent to minimize the significant side effects that psychiatric medications may have in a minority of patients.
Rather, my goal was to show that among well-informed psychiatrists, there never was a
“chemical imbalance theory” of mental illness in general; nor was such a claim put forth by the originators of the biogenic amine hypotheses.
To address some of Mr. Fiddaman’s concerns, I’d like to provide some perspective on
diagnosis and the use of “blood tests” in general medical care. There is a big difference
between investigational research and clinical practice. For example, I cited some
research findings on cortisol in melancholic depression. Though these are promising, and
may point to a “biomarker” for some types of severe depression, the diagnosis of
depression remains a clinical one; that is, it is made on the basis of the patient’s
history, signs, and symptoms. And, there is nothing wrong with that!
Psychiatry is often chastised for “not having any lab tests” to substantiate its diagnoses. But this charge could apply to much of general medicine. There is no “lab test”, blood test, or
X-ray that can diagnose migraine headaches, Lew Gherig’s Disease, or chronic facial
pain–these, too, remain clinical diagnoses, and are very “real” disease states.
Finally, though it is not the focus of my article, I would like to make a few comments
about antidepressants. The notion that “SSRIs” or other antidepressants can cause some-
one to commit suicide is far-fetched and simplistic; it is also not supported by
many carefully-done studies. A “chemical imbalance” theory of suicide makes no more
sense than a “chemical imbalance” theory of depression. Suicide is a complex personal
decision, and is influenced by many factors, including diagnosis, personality style,
support system, substance use disorder, etc. That said, I believe that a minority of
individuals who have bipolar disorder may become agitated and irritable when given
antidepressants (rather than mood stabilizers). Some of these individuals may become
suicidal in such a state, though the antidepressant is only one contributing factor. This is reason for extremely careful
diagnosis when the patient shows up with “depression.”
This brings me back to my basic point: human behavior and psychiatric illness are
both exceedingly complex. Neither can be reduced to a simple matter of “chemical
imbalances.” The psychiatrists I most respect understand that the whole person needs
to be considered–including the individual’s psychology, biology, social situation,
and spiritual concerns.And we in the U.S. need a health care system that allows those with emotional problems to find affordable and comprehensive care.
Ronald Pies MD
Dr. Pies,
Having read both this article and the one in Psychiatric Times I can not avoid a sense that this is revisionist history at best.
Having been through attempts at treatment with a very qualified and well regarded psychiatrist who certainly had excellent credentials, I think it is simplistic to explain away the “chemical imbalance” myth as something either promulgated by doctors who are being sloppy in their explanations, over-generous in their attempt to relieve perceived guilt on the part of the patient… or worse, the traditional patient blaming paradigm, that the poorly educated ill person simply did not understand the explanation properly.
I am here to tell you, in no uncertain terms, that my psychiatrist quite deliberately explained my bipolar illness to me in terms of chemical imbalance, a “broken brain”, etc. and explicitly stated that talk therapy, or any other non-pharmacological treatment could have no possible impact on the biological disorder I was suffering, except perhaps in teaching me to comply with treatment and cope with the burden of the illness. It was quite ironic as this practitioner also espoused acupuncture for certain illnesses and had studied mind-body psychology as a personal interest area, but saw no overlap between those notions and the biological basis of psychiatric disorders.
With modesty, I am hardly un-educated or ill informed, nor do I lack the intellectual capacity to understand a complex explanation. In fact, in my attempts at interacting with my doctor, I brought in journal articles to ask questions about, and before the field started to come to grips with the results of STEP-BD and other studies, was asking pointed questions about the efficacy and side effect profile of my treatment.
This was not well responded to. Evidently articles from PLoS and respected journals are merely internet nonsense or, when I produced a photocopy of the journal article in question, I was told as a layman, I couldn’t possibly understand what I was reading.
It was fascinating that, prior to my diagnosis and even after it, I had been considered an intelligent, reliable, thoughtful individual by those in my professional and personal life; however, after my diagnosis even my own doctor could see nothing but a patient who must surely correspond to all the known deficits of the illness model diagnosed.
I stopped medication after my personal experience with it proved incredibly destructive and not at all helpful in treating my symptoms. This was quite contrary to my doctor’s guidance. I also asked to stay in “treatment” so that my progress could be monitored sans medication. It was difficult to even get her staff to make an appointment for a “med-check” without meds, and calling it a “progress check” was completely out of bounds.
As my quality of life improved off the medication, despite a continuation of symptoms I’ve coped with all my life, I came to feel my decision was the right one for me. I ceased contact with treatment as I was tired of being harangued and threatened with all the terrible things that would happen if I didn’t resume medication.
I continued to read, STEP-BD came out shortly after and it was very vindicating to learn that the patient blaming that had taken place for lack of progress in treatment could not account for the fact that these medications were not helpful for the majority of persons taking them and came at quite a price in terms of other health risks…making the idea of taking them as a “just in case why not” not a benign option.
I still run across articles and even professional medical education pieces which blatantly refer to
patient non-compliance as evidence of their illness, unreliability, and unreasonable hypochondria regarding ‘rare’ side effects.
I’ve followed the discussion in the psychiatric community as they have tried to come to grips with the elephant in the room…namely that for a vast number of patients these medications do not work, and that for those who do benefit it is still very unclear why a benefit is seen or why one medication may help a certain individual and not another.
The internal debate has been sad and interesting to watch. It is clear that, as in many other professions, personal identity has become intertwined with professional accomplishment. The challenge to the paradigms for treatment have been resisted for this reason and, if I recall the term correctly from my reading, an ego insult has occurred as a result of accepting that the previous notions may be misplaced, that the pharma industry had behaved badly and taken a number of smart, educated people for a ‘ride’, and that they had not been as helpful as they might have wished to be. In fact, they may have even harmed some folks, however unintentionally.
I then read this article, by a man whose work I have read many times before, and I am saddened further. This re-casting of history and hair splitting between what had been said or not said before is unworthy.
Just as one might say to a patient, one must start first from a realization that is as honest as possible. I might be tempted to say nothing and let you work your way round to convincing yourself that mind-body is, and always has been the hypothesis espoused…except that I’m seeing the same blaming mechanism that has been so toxic to communication and treatment that has gone before, e.g.
The public has misunderstood, they hold populist notions, they lack the training to follow what they are told.
Lesser physicians, GPs perhaps or even maybe the less skilled in our own profession, have botched the explanation and need to be corrected.
Patients have been told what we think they can understand or something that will be kinder for them to hear.
Patients have deliberately misconstrued our explanation…sigh…what else can one expect.
This is the cancer in the psychiatric profession today. This defensiveness and ego coddling at the expense of science or listening to what your patients have been saying for years. Yes, the pharma industry did mislead you and in good faith or perhaps human weakness in a few cases, you fell for it. Well, even smart people can be fooled. According to P.T. Barnum, it is easier to fool a smart person and even when they begin to suspect…they insist on staying fooled rather than admit they’ve been conned. Barnum lived in fear of “stupid” people, as they had no ego inhibition for accepting their limit and simply responded, “I think that’s bunk.” Hopefully the profession will do some careful evaluation, keep what is useful, have a much firmer understanding of the limitations of the medications, and work on from there.
But in order to get well, to reestablish a connection with patients that you will need in order to make this new paradigm shift fruitful…you need to check your egos at the door. Stop blaming. Own up to your part in mis-communications. Accept prior mistakes. Move on to more productive strategies.
But those strategies will never be effective if you keep the same old bad habits as before.
I think you might say the same thing to one of your patients.
Dear Ms. Maine
I appreciate your frank critique of my article, and I respect the legitimacy of your own experience with the psychiatrist who provided treatment. I certainly don’t intend to excuse any inadequacies on her part, or any misinformation about bipolar disorder she may (per your account) have given you.
Unfortunately, even “very qualified and well regarded” psychiatrists are not always up to the challenge of communicating fully and accurately with patients. I’m sure I have fallen short from time to time, too—though, to my recollection, I never explained my patient’s problems as “due to a chemical imbalance.” Rather, like most academic psychiatrists trained in the 1980s, I was steeped in the “bio-psycho-social” (BPS) model of psychiatric illness, developed by psychiatrist George Engel. As the reasonably accurate article in Wikipedia describes the BPS, it is a
“…general model or approach that posits that biological, psychological (which entails thoughts, emotions, and behaviors), and social factors, all play a significant role in human functioning in the context of disease or illness…This is in contrast to the traditional, reductionist biomedical model of medicine that suggests every disease process can be explained in terms of an underlying deviation from normal function such as a pathogen, genetic or developmental abnormality, or injury.”
When we speak of “history” in psychiatry—and of “revisionist history”–we need to distinguish between the history of any particular patient’s treatment; and the history of psychiatric models and theories. It is the latter that my articles have addressed. It’s important to understand that the BPS is taught in nearly all medical schools and psychiatry residency programs, and is endorsed by American Psychiatric Association. [For a good review and critique of the BPS, see Dr. HR Tavakoli’s article, available for free on line (1)]. It is also the model used to test psychiatrists for board certification.
Unfortunately, for many economic and practical reasons, use of the BPS has suffered in recent years. Managed care has pushed psychiatrists toward providing less psychotherapy, and toward brief, “med check” appointments, as you observe. The real leaders in our field have been aware of the threat to an integrated, holistic approach for some years now. For example, see Gabbard and Kay’s article, “The Fate of Integrated Treatment: Whatever Happened to the Biopsychosocial Psychiatrist?” published in 2001, and available free online (2).
I am not trying to avoid responsibility or shift blame here—we psychiatrists have colluded too often in allowing our holistic philosophy to be subverted by the market place, and we need to own up to that. (For more on this, please see the article by my colleague, James Knoll MD, entitled, “Psychiatry: Awaken and Return to the Path.” [link is
http://www.psychiatrictimes.com/display/article/10168/1826785
Now, it turns out there are also weaknesses and problems with the BPS itself, which has been critiqued by Nassir Ghaemi MD, Niall McLaren MD, and others. For example, it is hard for many doctors to put the BPS into practice, even though they endorse the philosophy behind it. Some critics believe the BPS itself perpetuates the very split between “bio” and “psychosocial” it sought to curtail.
In any case, all this is just to say that when your psychiatrist “explained my bipolar illness to me in terms of chemical imbalance, a “broken brain”, etc. and explicitly stated that talk therapy, or any other non-pharmacological treatment could have no possible impact on the biological disorder I was suffering,” she was—in my view—greatly overemphasizing the biological model, and giving short shrift to the BPS. I don’t excuse this, but I understand why some psychiatrists wind up doing this; for example, some believe that by hammering away at the “biology” of the illness—which is definitely a major part of bipolar disorder—they will “convince” the patient to take medication and stay on it. I would argue that the goal is commendable for all but those patients with the mildest form of bipolar disorder—but the dogmatic method of “education” is not.
Furthermore, a purely biological approach misses the importance of psychological issues and stressors in persons with bipolar disorder. Once again, those I would regard as the “top people” in the field—such as Fred Goodwin, Nassir Ghaemi, and psychologist Kay Jamison—have recognized the importance of psychological factors in bipolar disorder for many years. In fact, Ms. Maine, if you get a look at the classic 2007 textbook Manic-Depressive Illness, by Goodwin & Jamison, you will find a beefy, 35-page chapter on the role of psychotherapy in bipolar disorder. The authors note that,
“While medication is the central treatment for bipolar disorder…psychotherapy is a particularly important adjunct to medication in maintenance treatment…[and] although biological variables predominate in the etiology [of bipolar disorder], the primary manifestations of bipolar illness are behavioral and psychological… psychotherapeutic interventions can be of unique value to patients undergoing such devastating changes in the way they perceive themselves and are perceived by others.”
Indeed, contrary to what you were apparently led to believe, “…some of the newer psychotherapies focus on monitoring these changes as a way of preventing recurrences.” (p. 870). I’m very sorry that someone of your evident sophistication was not provided with a more thorough and nuanced “risk-benefit” discussion of the treatments available to you.
I would have to disagree that medications for Bipolar Disorder are “not helpful for the majority of persons taking them”. In my experience, assuming treatment by an expert in bipolar disorder, most patients do receive substantial benefit from medication, especially when it is part of a broader treatment program, involving “talk therapy”, education about the illness, family therapy, etc. Unfortunately, there is still overuse of largely unhelpful medications (such as antidepressants), and under-use of quite effective agents, such as lithium (3).
By the way, Ms. Maine, the STEP-BD study you cite concluded that “…psychotherapy appears to be a vital part of the effort to stabilize episodes of depression in bipolar illness.” See
http://www.nimh.nih.gov/trials/practical/step-bd/questions-and-answers-about-the-step-bd-depression-psychosocial-treatment-trial.shtml )
I do respect the particular experience you have had, Ms. Maine, but it may not generalize to the majority of those treated for bipolar disorder. However, your comments are a good occasion to remind patients that obtaining a “second opinion” is often very useful, if you have doubts about the medical advice you have been given. And, yes, Ms. Maine, you are right: it is also an opportunity for all of us in the “helping professions”—particularly psychiatrists—to reflect on ways we could be doing a better job. I know we have a long way to go!
Ronald Pies MD
References:
1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2719450/?tool=pubmed
2. Gabbard GO, Kay J. The fate of integrated treatment: Whatever happened to the biopsychosocial psychiatrist? Am J Psychiatry. 2001;12:1956–1963. [PubMed]
3. Young AH, Hammond JMLithium in mood disorders: increasing evidence base, declining use? Br J Psychiatry. 2007 Dec;191:474-6
Dr. Pies,
Thank you for your detailed response.
I appreciate your valuing comments about the nature of my experience, I think you may find that a substantial number of patients are likely to have experienced something similar. It might well be worth a study of current perceptions on the part of patients.
I suppose if I were to do a cartoon I might possibly have in frame one two psychiatrists interviewing a patient who is describing his acquaintance with aliens living in his closet…both psychiatrists nodding sagely with the thought bubble over their heads, “Not in touch with reality.” In frame two I would have two patients attending a lecture given by a psychiatrist who was telling them that all these years they hadn’t had a chemical imbalance after all, and the field never believed they should have been led to believe so. The same thought bubble would then appear over the patients’ heads.
I suppose the point I might make is that, if what I suspect is true that more than a few of us received this information, the way forward entails a lot more effort in the part of correcting this misunderstanding than might be thought. I think there will need to be some bridge building on the part of psychiatrists in particular and a simple statement that you had not intended that we receive this impression may not really work to overcome the barriers to understanding that have evolved over time in terms of patient frustration…even if you can somehow reorient members of your own profession to communicate differently and re-craft their message.
Turning to a point of disagreement between us regarding the helpfulness of medication I offer the following quotes:
From
‘Treat to Remission’ Is Message of STEP-BD Study, Jim Rosack March 3, 2006 Psychiatric News Vol 41 Num 5
“For the predictors of recurrence analysis, Perlis and his team looked at a subset of the full patient sample, focusing on 1,469 patients who had at least two years of participation in the STEP-BD program. The researchers found that slightly more than half (858 patients, or 58 percent) of this group achieved recovery, defined as having no more than two symptoms of the disorder for a period of at least eight weeks during the two-year follow-up period.
Within that two-year window, nearly half of those who achieved recovery (416 patients, or 48.5 percent) relapsed; almost twice as many patients who relapsed suffered a depressive episode (298 patients, or 34.7 percent) than those relapsing to a manic, hypomanic, or mixed episode (118 patients, or 13.8 percent).”
and from the NIH page detailing information from the Acute Depression arm of the trial:
“Of the 179 participants who received an antidepressant in addition to a mood stabilizer, 24 percent achieved a durable recovery (at least eight weeks with no more than two depressive or two manic symptoms), compared with 27 percent of the 187 participants who took a mood stabilizer plus placebo. Moreover, adding an antidepressant did not increase the risk of a switch to mania or hypomania. The similar rates of durable recovery indicate that the addition of an antidepressant medication to adequate, optimally dosed mood-stabilizing medications does not improve recovery from bipolar depression any more than adding a placebo.”
We see from elsewhere in the document the definition used for remission was:
Durable recovery defined as an eight week interval with mo more than two symptoms present. Over the course of 1 year.
Remission, 2 weeks with no more than 2 symptoms over the course of the study.
And we are told further that this constitutes a rigorous definition given that as 1 week interval is set out by typical research studies.
I am sure that many in your profession have pointed out the obvious here…first in the extremely low bar set for a remission definition, especially in terms of an illness that by its nature is cyclic and where short intervals of relative “normal mood” can be expected to occur spontaneously in most patients from time to time.
In terms of signal to noise ratio, its very difficult for me to see one such short interval as being characteristic of much of anything except perhaps a lucky moment in an individual’s normal illness course, especially as the effect is not sustained reliably.
This aside, let’s look at the definition set out as remission from a qualitative standpoint. How many individuals would you know that would risk the side effect profile of some of these medications, medications with significant long term health risks when taken over time, for one or even two possible weeks of illness reduction over a year?
An exceptionally poor trade!
In terms of quality of life, where a patient may find, as I did, the medications limit professional activities, the ability to drive a car, the ability to engage in pursuits needing fine motor skills (such as music or graphic arts), the ability to use memory for complex multi-stage problem solving…etc We trade a year, or multiple years of a loss in these areas for a week or two of symptom reduction? Again a questionable exchange at best.
The article is focus on remediation of symptoms, it speaks little to remediation of quality of life or functional measures. I think this is a gap between what patients expect in terms of treatment versus what clinicians believe. For my part, and perhaps for others in my situation, the goal is functional recovery and participation in life. While symptom recovery would be a lovely thing, it takes a definite second chair to being able to participate in life.
I do recall reading some of the survey data sub-scales for STEP-BD where the data seemed to suggest that there was a qualitative improvement; however, what I did not see was a reference of this against measures of functional productivity on the parts of the patients in the self report data. Given the statistical data suggesting the vast unemployment or underemployment of BD patients, or their lack of ability to perform in competitive employ; I am left to wonder if this self-perception rating is against a benchmark altered by lowered expectations imparted by treatment itself.
In my case a number of memes emerged in the course of treatment, one seemingly that medication compliance is more important than functional goals. I was encouraged to put “recovery” before anything else…profession, artistic interests, even parenting. Recovery being defined largely by reports of medication compliance despite functional, symptomatic and qualitative declines in my case. While on one hand, one can appreciate that focusing on wellness is a primary responsibility, this notion became so conflated with the notion of medication compliance that I was effectively told that it was more important to take the medication than it was to worry over trivial matters like functioning in my life roles or doing things that might bring some joy or expression to the darkness I was experiencing. The medication was making it impossible for me to continue my work; engage in child rearing activities; engage in art, music, or photography (lithium tremor effectively destroyed my fine motor control and did some horrible things to my ability to work on complex programming tasks for work….and imposed some exceptional limitations on my ability to tolerate long commutes given its tendency to impose gastro-intestinal distress at very inconvenient moments.) The few things that I usually used to fight back against depressive thoughts, to debunk my negative self talk, and to comfort myself ceased to be available to me and I was told they were no longer important. Or, that I should prepare to give them up.
I have to say, if one isn’t already depressed, finding out that one can no longer engage in work, derive self-esteem and accomplishment from it, care for and be a custodial parent of a child, play the musical instruments one enjoys, express one’s feeling with art…will get you depressed in short order.
In short, when I confronted my doctor about all the things I had previously been able to do and was about to have to give up, I was told I needed to adjust my expectations.
Its this moment that I am referring to, the peculiarities of my personal experience aside, this lowering of expectation I think is something that is encouraged in treatment.
Should you wonder, it was the prospect of reaching a point where I could no longer economically provide for my child or be able to supervise her as a teenager (after having tried a week of Seroquel for the worsening depression) that finally got through to me. Despite all the confusion, fear, and debilitating depression, and my doctor suggestion I start looking at long term disability and assistance…I took stock.
Less than 6 months previous, oblivious to my diagnosis, I had been a well employed, responsible parent. I paid taxes, my bills, and met my obligations. I was no problem in my community. I was miserable and depressed, true. But I was coping and self sufficient.
I decided that any treatment that made me less able to cope, was a poor idea. Further, any treatment that interfered with me being able to provide for and parent my daughter was a failure. That was when I chose the left hand course.
So when self reporting on qualitative measures, I believe the results are skewed for those who have contact with treatment regularly. They are reporting subjectively against a new standard they’ve been led to accept.
Whether this is a good or perhaps even necessary thing is somewhat unclear point to me. I think all illnesses affect people to differing degrees and part of grieving the illness may involve accepting the loss of things one may have previously been able to do. But to exchange, wholesale, functional recovery and quality of life for the ability to continue taking medication…medication that has such poor symptomatic effects in particular…is to me highly questionable.
Turning to just the statistics involved…I can hardly think that a medication regime that produces a 2 week reduction for 58% of participants is something to rejoice over. When one then learns that of that 58% nearly half do not sustain that recovery and relapse repeatedly…the statistic becomes even less laudable. And the rate of those sustaining any kind of recovery without relapse looks to hover at about 30% of your original group.
Looking at the Acute Depression arm, depression being the bulk of disease burden for many, we are looking at figures where poly-pharmacy is producing remission rates in the mid twenties.
I stand by my statement that the majority of people taking these meds are not benefiting in terms of symptom recovery even when they are well monitored, supported, and given expert guidance.
That their functional recovery is questionable is easily seen in Labor and Statistics studies.
For those that do benefit I am extremely happy and wish them the best!
For those that don’t…there are few good reasons in my mind to continue them on medications after their ineffectiveness has been established in that particular person.
It is a matter for personal patient choice and perhaps professional clinician ethics to ask, how many years worth of medication tinkering and the associated risks in terms of health and loss of social function should be warranted in any given case? And, benchmarking the patient’s functional capacity prior to treatment it should be asked, has treatment improved functioning and quality of life or decreased it? This benchmark should be specific to the individual patient and not generalized to an overall view of what is popularly thought possible for a person with bipolar disorder. That is something that ought to be part of honest review at intervals between doctor and patient. Both doctor and patient should be ready to admit when things are not going well and adjust strategy, rather than merely persist on doing something that isn’t helpful because medication compliance is high.
Regarding psychotherapy…there is promise I think in this, but unfortunately I think there are very few doctors who have the skills and training to be helpful in this regard. I did try adjunct therapy…and although I had a lovely and kind doctor I did not receive the kind of help I needed. I valued the supportiveness and certainly that had a very significant benefit for a time; however, the kind of direction and practical assistance I needed wasn’t there.
I realize that that sort of thing is likely to be highly individual, and thus hard to train a clinician to do; but I’m not sure that clinicians have good resources to support them in this work.
It is quite difficult to try to find one’s way in devising coping strategies, identifying distorted thoughts and putting your own finger on moments where mood triggers are occurring while you are in the midst of them. Coming up with that on my own, with a bit of help from a few books by Beck who has been perhaps one of the most useful psychologists I have never had the privilege to meet, is a very flawed process.
Trying to communicate to a clinician what you need while you are discovering it yourself is nearly impossible. This makes coming together to devise strategy exceptionally frustrating for both sides.
I wish good luck to those who are seeking helping strategies in the cognitive field.
Stephanie
I appreciate Ms. Maine’s thoughtful reflections on her experience with BPD (bipolar disorder), and her comments on the study known as STEP-BD. And while I doubt this blog site is the best forum for parsing complicated research studies, I will have a few comments on the STEP-BD and other studies.
First, though, I want to say that anyone who experienced the side effects and frustrations described by Ms. Maine would be–quite understandably–very skeptical of the benefits of medication for BPD. It’s certainly true that the medications we now have for BPD are far from ideal; frequently cause side effects; and are not as effective for the depressive symptoms of BPD as for manic symptoms. And, alas, most important: BPD is, by nature, a highly-recurrent condition that tends to resist even the best therapy.
The issue, however, is not so much the absolute percentage of patients who achieve long-term benefits from being on medication (though that is important); rather, the issue is whether those taking appropriate medication are better off in important ways than those who do not take medication. The STEP-BD is merely one of dozens of studies that have looked at that question.
For example, in an analysis of five, randomized, placebo-controlled trials of BPD, Geddes et al (2004) concluded that lithium was clearly effective, reducing overall relapses to 65% of the frequency observed with placebo. That is, the average risk of relapse in the placebo group was 60% compared with 40% for lithium. This means that one patient would avoid relapse for every five patients who were treated for a year or 2 with lithium.[Geddes et al, Am J Psychiatry 161:217-222, February 2004]. In the Goodwin and Jamison text I cited earlier, the authors conclude, based on 11 “gold standard” placebo-controlled studies, that the average reduction in mood episode recurrence risk associated with lithium was 3.6 fold [p. 822].
Side effects of BPD medications are, as Ms. Maine’s account clearly shows, a big problem in terms of a patient’s staying on the medication (“adherence”). However, several studies suggest that side effects are not the most common reason for non-adherence to BPD medications. For example, a UCLA study of lithium adherence showed that the top reason for discontinuing medication was being “bothered by the idea that moods are controlled by medication.” The second most common reason was “missing highs”. Third was “feeling depressed” while taking medication. Feeling “less creative” or “less productive” were ranked 8 and 9, respectively [Jamison et al, Arch Gen Psychiatry 1979; 36 (Spec. No. 8), 866-69)]. Surprisingly, some studies show better adherence rates when patients are taking a combination of medications rather than a single medication.(In my experience, this is often because two medications can be combined at lower dosages, with fewer side effects, compared to just one medication).
All this said, rates of adherence to BPD medications are comparable to rates of adherence to general medical drugs, such as antibiotics [see chapter 20 in Manic-Depressive Illness]. And quite often—for example, with the cognitive side effects of lithium—a very slight adjustment of dose or blood level can make all the difference between tolerating or not tolerating the medication, in my experience.
As for “functional recovery” and quality of life—this is an area that has not received sufficient study, but some recent data suggest that medication for BPD (e.g., quetiapine) can have beneficial effects on quality of life (QOL) and ability to function [see Endicott et al, J Affect Disord. 2008 Dec;111(2-3):306-19. Epub 2008 Sep 5.]. Of course, the effect on QOL will differ from individual to individual.
There is a further, critical point to be made about taking vs. not taking mood-stabilizing medication. The lifetime suicide rate associated with bipolar disorder is in the range of 5-10%, depending on a host of factors. This is more than 10 times that of the general public. We have good evidence from several studies that lithium –and possibly other mood-stabilizers—substantially reduces this suicide risk. For example, Dr. Ross Baldessarini and colleagues found a 13-fold lower incidence of attempted and completed suicide among BPD patients receiving lithium, compared with those who did not receive it, or who had discontinued the lithium [see Baldessarini et al, J Clin Psychiatry, 2003; 64(suppl 5), 44-52. ]. For many severely affected persons, this benefit is more than worth the trade-off in side effects.
I realize that all this is rather far afield from the main point of my original blog, and may only reinforce the mistaken idea that psychiatrists think mood disorders are nothing more than “chemical imbalances.” So, once again: I believe this view of psychiatry is a myth! But clearly, my colleagues and I have our work cut out for us. First, we need to find better treatments for BPD and other psychiatric disorders. We need to focus more on “quality of life”, and not just on symptom reduction or remission. And, perhaps most important, we need to find better ways of communicating a holistic philosophy of what causes psychiatric disorders, and how they should be treated. As the physician Maimonides put it more than eight centuries ago, “The physician does not cure a disease; but rather, a diseased person.”
Signing off for now, Ronald Pies MD
Stephanie, my heart goes out to you. I believe your experience corresponds to that of many patients who find themselves worse off after so-called psychiatric treatment — including myself.
Dr. Pies, I agree with Bob Fiddaman. It certainly seems you are trying to have it both ways. Here is your published statement above:
“Since the late 1960s, we have discovered more than a dozen different brain chemicals that may affect thinking, mood, and behavior. While a few seem particularly important—such as norepineprhine, serotonin, dopamine, GABA, and glutamate—we have no quantitative idea of what the optimal “balance” is for any particular patient. The most we can say is that, in general, certain psychiatric illnesses probably involve abnormalities in specific brain chemicals….”
Really? Which chemicals, and what abnormalities? Medicine isn’t anywhere close to identifying either — but this seems to be a fairytale you cannot relinquish, no matter what you call it.
It really seems that you are attempting to disavow the embarrassment of the “chemical imbalance” theory — no, it’s not a plot by antipsychiatry, as you would have it — but you cannot give up the concept.
Given that this is the very picture of cognitive dissonance, your inability to clarify your position is understandable.
And it is inexcusably unethical for any doctor, GP or psychiatrist to use an untruth such as the “chemical imbalance” theory to convince a patient to take drugs. Your colleagues have been doing this for decades, not to console the patient but for their own convenience, as you very well know.
Dr. Pies,
I will try to respond to the major points although I agree we may have somewhat drifted off the original topic. Still, I think we may be coming back to it in unanticipated ways at points. I think in terms of perception and communication, and perhaps in terms of the specific points below we really are discussing how beliefs intersect with our understanding of science, medicine, disease and treatment. While the individual points in our discussion may seem far afield, I find myself coming back to the notion that they are deeply entwined with a reaction to the dichotomy you originally set out between mind-body and a chemical imbalance philosophy (biological reductionism).
I noticed your response in the Psychiatric Times blog and you appeared a bit miffed at your colleague. While I find it interesting that from his side of the fence that he may, for reasons of his own, share some of my perception that the ‘chemical imbalance’ notion was not quite as mythological as you feel it to be; what I find more interesting is an emerging sense on my part that this reminds me more of a problem in the study of historicism than anything else.
A quote:
http://abcnews.go.com/Health/BipolarTreatment/story?id=4359581
“This is an illness caused by changes in brain chemistry. And willpower alone cannot make this illness go away.” Interview with Joseph Calabrese, M.D., Director, Mood Disorders Program, University Hospitals Case Medical Center February 28, 2008
While we might possibly go back and forth about Dr. Calabrese’s meaning here, I can offer you the perspective of a layman in the climate in which treatment has taken place that the “take-away” from statements of this kind; addressed as a public education point to the general public before a national audience fuels the perception of the chemical imbalance viewpoint as far from mythological. Given I could probably find any number of similar remarks, the patient community is likely to experience cognitive dissonance on a massive scale if asked to believe that this was all a misperception.
Late in my undergraduate study I happened to take a graduate level course in history given by one of our emeritus professors. Ordinarily I would not have been in the course, both as an undergrad and because it was not my major; but nearing graduation I discovered a need for a general education credit that could not be met for scheduling reasons and did a deal with my academic advisor to substitute this course for the prospect of a very dismal general ed elective and possibly an additional semester before graduation due to schedule issues.
It was one of the most peculiar and changing classes I ever took, given by a very unusual and quiet man. I admit the first half of the class I had no idea what I was supposed to be doing, nor did my fellow students, and we all did dismally on the midterm. Finally, after an individual meeting with the professor to agree a topic for my final paper, I got the clue. It revolved around not just the critique of history (which we’d all produced in copious amounts for the midterm and been failed for to our collective puzzlement); but the perception and even manipulation of history by its participants and recorders…and the consequences when sub-groups held differing views regarding which version was correct. It was about the effect of the report on history on history itself. Needless to say my final paper was much more the thing and the professor very generously graded my entire semester on that work alone.
I think this is a point much more clearly understood today in the marketing and advertising industry, and certainly by politicians and their handlers on an intuitive level if not a conscious one.
The reason I bring this up, is that whatever the objective facts may be regarding the status of ‘chemical imbalance’ as a myth; the handling of the conflicting perception of how the notion came to be could potentially be as damaging as the notion itself if it becomes a focus for conflict, distrust, or further wedges both within the balkanized professional community of psychiatry (as you put it I think) and within the already fragile doctor-patient relationship.
The question is what do we do from here?
I think perhaps one way forward would be to minimize opportunities for this to become a point of division where different groups take their “history” to heart. Perhaps focusing instead on re-adjusting emphasis away from this characterization and away from biological reductionism in general might be helpful. Otherwise, I very much fear from a patient perspective that there might be damage to the relationship and understanding that ought to prevail when one side or the other feels invalidated or embarrassed either for promulgating a misunderstanding or participating in it.
A challenging and important point will be addressing how to reassure clinicians that telling a patient that they do have some impact on their symptoms and, more importantly how they choose to react to them; can be done without it being seen as encouraging non-compliance with medication on their part. I don’t think either side reflects often enough on the distorting effect that this control issue has on the doctor-patient communication…encouraging doctors to over-generalize, gloss over information when obtaining consent or describing likely effects of treatment and patients to be deceptive about medication behavior, non-engaged and distrustful.
Mind-body paradigms require a great deal of engagement on the part of the patient and mutual trust between practitioner and patient. The doctor must trust the patient to receive information and act appropriately. The doctor must trust the wellness instinct of the patient. The doctor must respect the patient’s choices and priorities in establishing wellness. The patient must actively listen to the doctor and seek to understand clearly what is being explained. The patient must respect the experience and perspective of the doctor, particularly in cases where the illness may interfere with clear-sightedness on the part of the patient. The patient must invest effort in developing helpful cognitive strategies for coping with their illness.
That can’t happen if the doctor doesn’t trust the patient enough to admit to them that they have a role to play in their recovery and withholds information about the effects of treatment in an attempt to coerce medication compliance. It also can’t happen if doctors are unrealistic in their views of just how helpful a medication is likely to be. It can’t happen if doctors are unwilling to engage in “the other half” of treatment.
It also can’t happen if patients just expect to take a pill and have everything be “all better”. Or conversely, for people whose symptom profile produces severe problems interacting with others and destructive behaviors, patients can’t expect that cognitive strategies alone will be sufficient to curb negative behaviors and may need to accept whatever level of medication can inhibit this destructive behavior.
Given the inclusion of so many patients as part of the “bipolar spectrum”, clinicians may need to become more skillful in identifying where their individual patients are in terms of connecting with treatment. It may not be appropriate to use the same strategies with one cluster of symptoms as with another. My individual experience is that that fine tuning is missing in treatment. It isn’t a matter of severity, or even classification of type of bipolar I think. I don’t feel it is meaningful or even appropriate to tell one bipolar person that their suffering is easier or harder than anyone else’s. My depression as BP NOS may be as bad as or worse than a BP I, I have no way of knowing. What I do know is that the particular way my cluster of symptoms affect me allows me some choices than some other patients might not have and I exploit that. I do think that the individual’s symptom profile can vary widely, and that variation may make them better or worse candidates for particular strategies. Work in parsing that I think would be a legitimate focus for researching interested in mind-body strategies.
Moving to other points in the discussion…
You remark, “The issue, however, is not so much the absolute percentage of patients who achieve long-term benefits from being on medication (though that is important); rather, the issue is whether those taking appropriate medication are better off in important ways than those who do not take medication.”
I think this is probably quite true for some. It is not, however, well reflected in the experimental design of most studies or the rating scales used to determine symptom severity. This makes it difficult to accurately determine just how many patients are benefitting and in just what way. I find this surprising. I would have expected to see outcomes measures that were more descriptive of functional recovery; role based functioning, or qualitative improvement in terms of a patient’s individual benchmark. I have seen study designs that focus on overall reduction in symptom severity scores and, as you note, a number of studies on relapse rates.
Looking at symptom severity scales I have wondered why I have never seen an effort to capture data regarding “limiting factors” or “deal breaker” symptoms. I think you are right that some patients who find a benefit may not reflect in measures that deal only in a bulk reduction of symptoms and that this is not reflected in the study data in a clear way. When I consider what might cause a person to benefit what comes to mind is the idea that an individual may have a particular symptom or set of symptoms that are uniquely intolerable to them and that resolution of this may make a medication trial a failure or success regardless of the rating scale measure presently used. Thinking of an individual I have spoken with who found her medication treatment a “qualified” success, she found the medication helpful because it reduced her most offensive symptoms, intrusive voices. She was willing to put up with her side effects and a lack of reduction of other symptoms in almost all her other areas for this one point alone. I could easily see her as scoring relatively poorly in terms of overall symptom reduction despite feeling there had been important progress. Others I have spoken to have mentioned that it was frustrating for them because their doctors saw them progressing in treatment due to a general reduction in score, while they found the treatment not worth the risks as their most troubling symptoms were not reduced and their side effects were high.
I’m not sure how an appropriate metric would reflect this, but surely some weighted system might be devised as a parallel method in these kinds of studies that ranked or weighted symptoms according to a “personal intrusiveness” measure the participant supplied. I’m not sure having an absolute ranking/weighting would be a good idea considering that the fellow I was mentioning in the last example above also heard voices but had a pretty effective cognitive strategy that made them less concerning for him than they were for my female acquaintance. Having some kind of subjective, individual indicator might make these studies more descriptive of patient experience.
In terms of the relapse studies you mention, again the usefulness as an indicator may vary greatly by patient. I can well see some patients finding it a relief to not bounce from one mood state to another, or for those with very destructive courses, the fewer instances of high consequence mood states may be exceptionally attractive. However, given the number needed to treat you cite it may be that those with serious side effects concerns would be less swayed by this indicator. A patient might also be influenced by a review of their particular pattern of illness episodes.
I recall reading an author once discussing the difference between efficacy, statistically significant and clinically significant. I thought it a very helpful thing to consider.
You go on to mention reasons for medication discontinuation and cited Jamison et al, Arch Gen Psychiatry 1979; 36 (Spec. No. 8), 866-69). With respect to the authors, I would like to offer some more recent citations and also a few observations on this. I think it is an exceptionally important point and perhaps goes back to what I was referring to earlier in terms of historicism. It certainly bears on a communication and perception issue between doctors and patients, one that may well have been a point of manipulation at various times over the last several decades by industry interference.
Your suggestion based on Jamison was that the chief reasons for medication non-compliance were not side effects that they were: “being “bothered by the idea that moods are controlled by medication.” The second most common reason was “missing highs”. Third was “feeling depressed” while taking medication. Feeling “less creative” or “less productive” were ranked 8 and 9, respectively” This author was particularly referring to lithium and at the time I don’t believe (please correct me if I have my dates on availability mistaken) that the atypicals or some of the mood stabilizers in use today were available.
I think there may have been a number of factors involved in this finding. One might be the diagnosis of bipolar itself has changed considerably through the inclusion of spectrum disorders. It seems likely to me that many of this study’s respondents were likely to experience the classic manic states a bipolar I would be expected to experience. I may be mistaken but I seem to recall one couldn’t even be properly be diagnosed bipolar at that time unless one’s symptoms had severe enough to lead to hospitalization in the ‘70s. Missing highs might well be a response for patients in this group. I also think this group is likely to be more severely disrupted in terms of work and endeavors, possibly explaining why productivity went to the bottom in the reporting.
The response of feeling more depressed is certainly supported by Cade’s original research on lithium. Personally I can vouch for this experience while on lithium. This would mean that a side effect, increased depression, was the number three reason for discontinuation even in this early study.
The most common response, being bothered by the idea that moods are controlled by medication, seems a reasonable response for a patient to bring up, especially at that time when patients and the general public were less aware of the effect of biochemistry on our mood. While I realize that most doctors see this as a negative indicator, this is actually a sign of the “will to be well”, a wish to be self-directing and to take charge of one’s inner state. This is a HUGE boon in terms of a mind-body paradigm, it is an enormous threat to a more control driven doctor-patient relationship in a reductionist biological model.
I have read some authors who have strongly advocated making the reluctance to take medication as a symptom of the illness. This medicalizes a healthy impulse!
A quote:
“Patients who persistently disapproved of the decision to override their treatment refusal were highly grandiose, engaged in denial of psychotic proportions, and responded poorly to treatment. The results suggest that, for most patients, the decision to refuse psychotropic medication is a manifestation of the patient’s illness and does not reflect autonomous functioning or consistent beliefs about mental illness or its treatment. ”
Autonomy and the Right to Refuse Treatment: Patients’ Attitudes After Involuntary Medication Harold I. Schwartz M.D., William Vingiano Ph.D., and Carol Bezirganian Perez M.D.
I am not saying that this idea should be allowed to stand unchallenged as an attitudinal impediment to appropriate medication compliance. I am saying that it is a wonderful place to start in redirecting this self-directive impulse towards things the patient can control…like how they choose to respond to a mood state, how they wish to direct their treatment, devising cognitive strategies. And, mind-body can diffuse the underlying assumption behind the patient concerns: ONLY chemicals control the mood and therefore me > doctors control what chemicals I take, that control me > doctors control me. Hence, rebellion. This entire thought train can be derailed by an acknowledgment from doctors that it’s a dual effect, chemicals and cognition and by giving the patient strategies they can use to address their mood states and resulting behaviors.
It didn’t have to happen for these patients, and this particular reasoning wouldn’t need to keep happening in most cases if the biological model were somewhat less relentless.
The communication between doctors and patients on matters of compliance seems to be one of the most tortured dialogues of human experience. Communication is tricky enough with each hearing the other through filters of experience, fear, and frustration. I think it has also been manipulated by industry to delay a realization by physicians that things were not quite what they seemed in terms of medication results.
A lack of sophistication on the part of patients has had a huge role to play. I believe that we simply didn’t know how to express things in terms a doctor could accept and respect. Consider a remark like, “I don’t want medication because its poisoning me.” From a medical perspective I imagine a doctor might be tempted to find the patient is probably paranoid, irrational, delusional, or very ignorant. This is because the doctor knows, “Medication is not poison. I want the best for this person. I would never intentionally harm them. It will make them better.” But, the patient may not be paranoid or delusional, perhaps not even wrong. If the statement were instead, “I don’t want the medication because I think it may be having a toxic effect, my hair is falling out, I have abscesses, and diarrhea. I feel confused all the time when I take it.” The doctor is likely to have a very different response, and hopefully will order some tests to see if the medication is causing a problem.
Patients and cultures evolve just as medical paradigms do. Looking back at older research on patient attitudes may need to take into account the miscommunications, the inarticulate expressions, and the missed opportunities for understanding.
But patients are always first on the scene and sometimes, just sometimes, they have the facts before a pattern emerges for the medical profession to discern.
Back when I was researching, trying to decide if going out of treatment was an absolutely foolish notion or not, I ran across the following paper: Attitudes and beliefs among patients treated with mood stabilizers, Lars Vedel Kessing, Hanne Vibe Hansen and Per Bech, Department of Psychiatry, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark; Psychiatric Research Unit, Frederiksborg General Hospital, Hillerød, Denmark, Clinical Practice and Epidemiology in Mental Health 2006, 2:8
It was very interesting and I contacted the authors with questions. They were kind enough to respond. In the research they have devised an attitudinal questionnaire for medication. The results were very interesting to me in terms of this potential communication gap. While the patients scored very highly on the measures the researchers devised regarding how to correctly take medication and so on, they ran into trouble on the measures dealing with the effects of mood stabilizers. These were scored as “non-correct” attitudes by researchers largely because they didn’t correspond to the medical view. What fascinated me is that I could experientially understand exactly why the patients responded as they did, and had shared the experience. The researchers stood by their views but did reluctantly begin to follow the alternative view I gave them. We were somewhat hampered by their English, which was quite good but perhaps not nuanced. Unfortunately I was unable to communicate in their language at all.
From the study: “In contrast, a large proportion of the patients had non-correct views on the effect of mood stabilizers (Component2 (Preserved autonomy)). A total of 77.4 % of the sample of patients agreed on item 1 that as long as you are taking mood stabilizers you do not really know if they are actually necessary. Accordingly, 50.0 % agreed on item 3 that when you have taken mood stabilizers over a long period of time it is difficult to stop taking them and 37.3 % agreed on item 6 that when you take mood stabilizers you have less control over your thoughts and feelings. Further, 41.7 % agreed that mood stabilizers can alter your personality (item 9) and 49.8 % that your body can become addicted to mood stabilizers (item 13) and accordingly 36.1 % agreed that your body can become immune to mood stabilizers (item 24). A total of 61.0 % agreed that their depression and/or manic episodes are mainly due to factors associated with their personality (item 31).”
When I was in the service we had a saying, “There is the right answer, the wrong answer, and the military answer.” I think this is a similar case. While the “treatment answer” is that taking mood stabilizers is always necessary and will be for all of your life, in point of fact you actually do may not know as a fact whether maintenance treatment has reduced episodes or symptom severity in your particular case while you are still taking them. Some patients may see this, others may be the 4 unlucky fellows out of the 5 needed to treat for a patient to see an episode frequency decrease. The treatment answer is, or was at the time, that the medications prescribed in most cases were not addictive or habit forming. Yet we know now that some have proven to have difficulties, withdraw syndrome (addiction short the element that increased dosages are required for the same effect); and personal experience of anyone going off of mood stabilizers will generally be that it is an uncomfortable experience. My experience was. And the literature suggests that rebound symptoms or effects that mimic symptoms are common during discontinuation. Yet, the study scores the 50% of patients here as incorrect in pointing it out. Immune to mood stabilizers? Perhaps an inexpert way of saying the medication ceases to be effective.
There is perhaps a difference between how a layman defines personality and the clinical definition of it that causes some concern for some of these measures, the author and I went back and forth on that a bit; subjectively if we are less aggressive as a result of lithium (an effect observed by Cade) it seems likely that this would be perceived as a personality alteration by a layperson. As to having less control over your thoughts and feelings, the treatment answer may suggest that medication should lead to increased control over these things…but my personal experience was that I experienced a lessened ability to cope, rationalize and deal with the magnitude of my feelings while on medication, and so I side with the study participants on that as a valid description of experience even if it is not supposed to be the case with a mood stabilizer.
As to the episodes being caused by personality factors…that is an opinion on the part of patients that merely violates the biological view. It may be an inexpert way to express the fact that they sensed that their experiences and learned responses had some part to play in their illness course.
The patients were wrong because they failed to concur with the bio-medical paradigm of the illness and reported their experiences. They had something interesting to say, and yet, was it heard as anything other than a dysfunctional attitude?
In terms of explaining ourselves to one another, we have a long way to go. But clinging to our belief systems and paradigms are barriers to understanding.
Returning to the point of compliance more directly I offer the following:
Medication non-adherence in bipolar disorder: A patient-centered review of research findings, PERLICK D. A. ; ROSENHECK R. A. ; KACZYNSKI R. ; KOZMA L., Clinical approaches in bipolar disorders , 2004, vol. 3, no2, pp. 56-64
“To evaluate the prevalence and predictors of this problem we identified 25 papers on medication adherence published between 1979 and 2004. Non-adherence ranged from 23% to 68% and the most consistent risk factors were: co-morbid personality or substance abuse disorders; self-report of side effects; single marital status/living alone; limited family or clinician support; and limited insight/knowledge about bipolar disorder.”
Self-Reported Medication Treatment Adherence Among Veterans With Bipolar Disorder; Martha Sajatovic, M.D., Mark S. Bauer, M.D., Amy M. Kilbourne, Ph.D., M.P.H., Julia E. Vertrees, Pharm.D. and William Williford, Ph.D., Psychiatr Serv 57:56-62, January 2006
“This study was a cross-sectional analysis of patient characteristics, features of the patient-provider relationship, and barriers to care as they related to self-reported treatment adherence among veterans with bipolar disorder. Data were collected before patients were randomly assigned to treatment in a multicenter trial. Participants were enrolled in the study from 1997 to 2000. RESULTS: This analysis found that individuals with bipolar disorder who were adherent to medication (N=113) differed from those who were not (N=71) on patient characteristics and variables related to the patient-provider relationship. Individuals with bipolar disorder who were not adherent to medication were more likely than those who were adherent to have a current substance use disorder. A past substance use disorder was not associated with treatment nonadherence. Adherence to medication was not predicted by symptoms, overall health status, functional level, or gender. Individuals who were adherent to medication took a greater number of different medications than those who were nonadherent.”
Adherence to medication in bipolar disorder: a qualitative study exploring the role of patients’ beliefs about the condition and its treatment; Jane Clatworthy, Richard Bowskill, Tim Rank, Rhian Parham, Rob Horne, Bipolar Disorders vol 9 Iss 6 Sept 2007
“Thirteen participants (81%) reported some degree of intentional or unintentional medication non-adherence. Intentional non-adherence was associated with patients’ concerns about the prescribed medication, arising from the experience of side effects, but also from beliefs that regular use could lead to adverse effects in the future. Intentional non-adherence was also associated with doubts about the personal need for medication, which were related to perceptions of BD (e.g., not accepting diagnosis, believing the condition is not controllable, believing it is not a chronic condition).”
It seems from these there is a change in how patients are responding regarding medication compliance decisions with substance abuse leading the way unfortunately, but with other concerns as to effects and perhaps ability to sustain treatment while living individually without supports being an issue of high concern.
I would simply suggest that patients’ concerns have more validity than might be supposed when carefully explored and listened to. Efforts to paint patients as incapable of understanding, in love with their symptoms, or uneducated about their illness fall short of the truth in many cases and may not be the descriptors best attributed to the majority of the patient population. This divide of understanding and communication is a serious one.
As to suicide risk, I have seen the studies that you suggest. Again, making a medication choice for an individual in hopes of suicide risk reduction may be flawed. Just as you yourself argue elsewhere in the blog that anti-depressants cannot be seen as the single causative factor in increases in suicide completion, I suggest that these studies do not control well for other factors that may be contributory or inhibitory to those inclined to end their lives. I understand that physicians have an additional personal risk in legal terms in doing what they can to avoid our litigious society and do not envy having to factor that into decision making.
It is unclear to me what is the cart or the horse when it comes to those who go off medication and suicide. It may be that they are suffering from the effects of the sudden discontinuation of the medication that accounts for the effect…just as it contributes to increased relapse reports in some of the recurrence of illness studies. It may also be that the person may decide while on medication that they will make this effort and go off medication to ensure that they are clear enough to complete the attempt. I suspect for those who are serious and considered in their decision that may be all too likely. It may be that the medication suppresses impulsiveness and is a successful inhibitor of suicidal behavior for some, or that it leaves them too disorganized to successfully complete an attempt. Or it may be that the medication truly improves the outlook of the patient sufficiently to alter their plans and keeps them from an awful alternative.
My personal suggestion, from a mind-body standpoint, is the best cure for suicidality is emersion in life. If the treatment takes you further from goals, or effectively leaves someone with no engagement in life that has meaning, I feel risk goes up regardless of what medication you may have on board. I am a strong advocate of Frankl’s views in this regard. Some give up on a sunny day, others persist in a pit of evil and darkness, or so was the message I took away from his, In Search of Meaning. The why of that is a personal journey that I feel medication is probably not going to be a good substitute for. If anywhere, this is the area where mind-body strategy, cognitive therapy, and rehabilitative supports need to be key.
Perhaps others of us are just too stubborn to give up!
Dear Dr Pies,
With respect, some of your comments here are very misleading and go against what both the pharmaceutical industry and medicine regulators state.
You wrote:
“I would like to make a few comments
about antidepressants. The notion that “SSRIs” or other antidepressants can cause some-
one to commit suicide is far-fetched and simplistic; it is also not supported by
many carefully-done studies.”
What studies have you been reading? Have you ever heard of the Paxil 329 studies?
Are black box warnings added to boxes because it makes the packaging look pretty?
I guess you are from the school that blames the “illness” rather than the medication, right?
Could you explain the suicides and attempted suicides in healthy clinical trials on SSRi’s?
Do you oppose what the FDA, MHRA, indeed the global regulatory system claim that SSRi’s can cause suicidal thoughts and suicide? It appears that you do.
The chemical imbalance theory was a promotional tool. Consumers were fed the line, “You are depressed because you have a chemical imbalance, X,Y,Z can correct that imbalance.”
We now know that was an outright lie, it was a genius marketing strategy to sell drugs and to dupe the public.
Your headache analogy is wafer thin, I’ve never known anybody to take a headache tablet twice a day for 10, 12, 15, 20 years to ‘cure’ their headache, have you?
If you were to be totally honest Dr Pies, you would tell your readers that there is much evidence to suggest that SSRi type medication can cause suicidal thoughts and suicide in a number of patients that take them…or do you totally dismiss the abundance of anecdotal evidence that exists today?
I am astounded that you deny there is an SSRi/suicide link and, to be quite frank, fear for any of your patients that you prescribe this type of medication to.
If one of your patients came to you and said, “Hey Doc, I have just read the warning on the patient information leaflet and the drug you prescribed me can cause suicidal thoughts and suicide.” Would you tell him/her that the information provided is “far-fetched”?
When taking an SSRi, one alters the chemicals in their brain with the medication, therefore giving the patient a chemical imbalance, an imbalance that wasn’t there before they started taking the meds, or at the very least could not be proven existed before the start of medication.
Remember Dr Pies, healthy volunteers in clinical trials who went on to either have suicidal thoughts or to complete suicide only did so because of the drug they were taking. For you to dismiss this is dangerous, unethical and downright ignorant.
It would appear that you are not going to alter your opinion on this matter, that could have dire consequences on any of your future patients who come to you with their concerns about the medication you have prescribed them.
Next you will be telling me that there is no addiction problem with SSRi’s.
Bob Fiddaman
Author of ‘The evidence, however, is clear…the Seroxat scandal’
The issue of suicide is extremely complicated, and it always astounds me that some who vehemently reject the notion of a “chemical imbalance” as a cause of mental illness credulously embrace the idea of a “chemical imbalance theory of suicide.”
Suicide is a diverse, multi-caused, existential decision, that involves a complex interplay of numerous risk factors. Substance abuse, chronic illness, age over 75, parental history of substance abuse, and poor social supports are all risk factors for completed suicide. However, the best-established risk factor for completed suicide is the presence of a major mood disorder itself.
The American Association of Suicidology notes that the risk of suicide in people with major depression is about 20 times that of the general population. Individuals who have had multiple episodes of depression are at greater risk for suicide than those who have had one episode. [For more information, see http://www.suicidology.org/web/guest/stats-and-tools/fact-sheets
Similarly, the suicide rate in bipolar disorder is many magnitudes higher than in the general population, and there is good evidence that the use of lithium reduces the risk of suicide very substantially [see see Baldessarini et al, J Clin Psychiatry, 2003; 64(suppl 5), 44-52.]
With regard to antidepressants (ADs): the term “suicidality” is very loosely used in the literature, and often, FDA and pharmaceutical company data do not carefully discriminate between, for example, having “suicidal thoughts”; making a suicidal “gesture”, such as a superficial cut on the wrist; or a serious suicide attempt using lethal means.
While a small percentage of individuals (mainly children and adolescents) may experience suicidal thoughts or exhibit self-injurious behaviors while taking an AD—usually early in treatment–there is no convincing epidemiological or clinical evidence showing any significant increase in completed (actual) suicides associated with AD use.
Thus, in the U.S., a joint meeting of the Psychopharmacologic Drugs Advisory Committee and the Pediatric Drugs Advisory Committee in September 2004 analyzed the short-term placebo-controlled trials of nine antidepressant drugs. The results demonstrated “a greater risk of “suicidality” during the first few months of treatment of those receiving antidepressants. The average risk of such events on drug was 4%, twice the placebo risk of 2%. No suicides occurred in these trials” (www.fda.gov).
In fact, there are several cross-national, epidemiological studies suggesting that antidepressant use may reduce the risk of suicide attempts and completed suicides. For example, a recent 27-year observational study of antidepressants [Leon et al, J Clin Psychiatry, 2011;72:580-586] concluded that “…antidepressants were associated with a significant reduction in the risk of suicidal behavior”, which was defined as a reduction in actual suicide attempts or completed suicides, while taking ADs.
Similarly, A study of suicide rates and antidepressant use in the U.S.(1996-98) concluded that “increases in prescriptions for SSRIs and other new-generation non-SSRIs are associated with lower suicide rates both between and within counties over time…” [Gibbons et al,Arch Gen Psychiatry. 2005 Feb;62(2):165-72].
Another study in Hungary examined the connections between suicides and the consumption of antidepressants in the period of 1999-2006 [Kalmar S,Neuropsychopharmacol Hung. 2011 Jun;13(2):59-72.] The study concluded,
“The results of the analysis supported the hypothesis that in spite of some contradictions, there is a connection between the increase in antidepressant use and the decrease in the number of suicides. The increased use of antidepressants is one of the factors contributing to the decrease of suicides.”
That said, many mood disorder specialists do become concerned when a patient with bipolar disorder–often misdiagnosed as having unipolar major depression–becomes agitated and irritable while taking an antidepressant. This may well increase that person’s risk of acting out in a self-injurious manner, or becoming violent. This is owing to the inappropriate use of antidepressants, in individuals who are best treated with mood stabilizers and supportive psychosocial therapies.
Now, regarding “addiction”: while the term “addiction” is variously defined and understood, there is no credible evidence that antidepressants are “addictive,” in the sense physicians apply to addiction to opiates, sedatives, barbiturates, alcohol, and related substances.
However, there is a subset of patients who may become resistant to their antidepressant, over time. Furthermore, inappropriately rapid discontinuation of an antidepressant can lead to an uncomfortable withdrawal syndrome, usually characterized by a flu-like syndrome of nausea, vomiting, muscle aches, and fatigue. Usually, this is short-lived, and reversible with restoration of a small dose of the medication. This syndrome is quite unlike the potentially life-threatening withdrawal syndrome seen, for example, when someone goes “cold turkey” off barbiturates.
That said, for a small minority of patients whose antidepressant was discontinued too quickly, their withdrawal effects may persist for weeks or even months, based on some case reports. The key to avoiding these problems is to taper the medication very, very slowly–over a period of 3-6 months, in my experience. In a practice extending over 25 years, and several hundred depressed patients, I never witnessed, or consulted on, a serious withdrawal reaction from antidepressants, when a very slow tapering period was used.
Finally, it is a shame that a few mendacious fear-mongers, with no medical training, continue to prey upon the anxieties of those already struggling with a life-threatening condition, and who find antidepressant medication–ideally, in combination with psychotherapy–a life-saving treatment.
Ronald Pies MD
Dr Pies wrote:
“The issue of suicide is extremely complicated, and it always astounds me that some who vehemently reject the notion of a “chemical imbalance” as a cause of mental illness credulously embrace the idea of a “chemical imbalance theory of suicide.””
My answer:
One only has the imbalance when one starts the medication. It really doesn’t take Einstein to work this out.
Dr Pies wrote:
“While a small percentage of individuals (mainly children and adolescents) may experience suicidal thoughts or exhibit self-injurious behaviors while taking an AD—usually early in treatment–there is no convincing epidemiological or clinical evidence showing any significant increase in completed (actual) suicides associated with AD use.”
My answer:
So there has never been a completed suicide in any antidepressant clinic trial with healthy volunteers? Are you saying that the FDA are lying?
Dr Pies wrote:
“Similarly, A study of suicide rates and antidepressant use in the U.S.(1996-98) concluded that “increases in prescriptions for SSRIs and other new-generation non-SSRIs are associated with lower suicide rates both between and within counties over time…” [Gibbons et al,Arch Gen Psychiatry. 2005 Feb;62(2):165-72].”
My answer:
Gibbons also objected to the black box warnings and is a paid ‘expert witness’ for GSK in litigation regarding Paxil. Hardly an independent view is it?
Re his study [above] Gibbons was wrong. The suicide stats he analyzed did not yet reflect the effect of the black box warnings and he ended up having to tell the New York Times the “early evidence” was actually not evidence at all but “suggestive.” If you are going to quote ‘experts’ then please do your homework Dr Pies.
Dr Pies wrote:
“Now, regarding “addiction”: while the term “addiction” is variously defined and understood, there is no credible evidence that antidepressants are “addictive,”
My answer:
Well, it took me a total of 22 months to taper off Paxil. I am one of many thousands…or do you not accept anecdotal evidence?
Dr Pies wrote:
“Finally, it is a shame that a few mendacious fear-mongers, with no medical training, continue to prey upon the anxieties of those already struggling with a life-threatening condition, and who find antidepressant medication–ideally, in combination with psychotherapy–a life-saving treatment.”
My answer:
Not one single pharmaceutical company have carried out any study in relation to long term use of SSRis yet you, an MD, profess that these drugs are safe. The only ‘fear-mongers’ are the ones who promoted these types of medications with the “chemical imbalance” spin. It was never proven back then…and it has never been proven to date. They were promoted on a lie – surely that should raise alarm bells for even the most stubborn of individuals.
You refer to a very slow tapering regime – how slow? Who tells the doctor how slow to taper the patient?
Do you prescribe Paxil to women who are pregnant Dr Pies? Do you know it is a known teratogen? [See GSK V Kilker]
Patients should have informed consent, you owe it to them to warn them of the dangers…and not just the dangers written on the patient information leaflet. Read through the product monographs of all the SSRis then answer the following:
What are the benefits of taking an SSRi?
and
What are the risks?
I think you will find that the benefits clearly do not outweigh the risks.
Bob Fiddaman
Author of ‘The evidence, however, is clear…the Seroxat scandal’
“Finally, it is a shame that a few mendacious fear-mongers, with no medical training, continue to prey upon the anxieties of those already struggling with a life-threatening condition….”
Dr. Pies, there you go again with the ad hominems. This is inflammatory and, as even you know, dirty pool in debates.
Plus, it indicates you have no respect for those injured by psychiatric treatment, and, because you so deliberately deprecate what they have to say, no interest in reducing the rate of those injuries. So it makes you look bad, doubly.
Again, I suggest you use your position to help patients by urging psychiatry to fill the gaps in the risk-benefit analysis and do honest studies of long-term adverse effects — as well as short-term adverse effects, such as suicidality. Psychiatry really circled the wagons on that one!
May I point out the rate of suicide is perhaps .0125%, while psychiatry’s estimated rate of depression ranges from 10%-50%. Obviously depression is no predictor of suicide. If vast numbers are being medicated prophylactically, they are being unnecessarily exposed to risks. Has there been some fear-mongering about suicide to promote antidepressants?
On the other hand, doctors have a higher rate of depression than the non-MD population. Perhaps they should start on antidepressants in medical school? It costs so much to train them, and they are so valuable to society, we wouldn’t want to lose even a fraction of a percent to suicide.
Up until this point I had been directing my comments solely to Dr. Pies, but I would like to interject for a moment into what appears to be a discussion that is headed downhill in roller skates.
Is this helpful?
Clearly, Dr. Pies has spent a career attempting to find positive ways to impact on those suffering mental illness. His profession is at a turning point where many uncomfortable realizations are coming to light about previously held paradigms, and where he is clearly making an effort to redirect focus away from a purely biological model of illness.
I think we should honor his intentions. Even if our individual experiences may not always accord with his views. I also think its a bit much to hold him personally to account for explaining and justifying the attitudes, beliefs and history of an entire profession…whether he may endorse those beliefs to one degree or another notwithstanding.
Alternately, not all those who find current thought in the psychiatric community questionable are automatically anti-psychiatry, anti-treatment, or out to stimulate fear or promote disinformation. Nor are they out to invalidate the efforts of the medical community in seeking solutions for those experiencing these illnesses.
If we allow our frustrations, from either side, to drive each other from the discussion, no good is served.
We need to hear each other.
From the patient side, the message I am taking from the other posters, and one that I feel myself, is that there is frustration that the information in the research studies may not well reflect our experiences. And, that those experiences are regarded as being more common than we are led to believe.
On the physician side, the message I am hearing is that doctors are proceeding as best they can based on the information from the study results and their practices.
In my other post I touched on areas where I believe we have been fundamentally missing each other in our communication. A gap has definitely formed.
I think the confounds are that there is another player in the communication that has skewed the information received by both doctors and patients, who has been implicated in selectively publishing their data, cherry picking subject pools, underwriting the medical education lectures physicians receive, manipulating academic reviews and drug approval processes, using statistical treatments and relative risk statistics most advantageous to their position, funding patient information and support groups that promote their message, and who…for reasons completely compatible with capitalism but not very compatible with science or medicine, has stimulated a distrust of patient report data from a population that already has a massive problem with perceptions of credibility.
Another consideration is the schema for patient visits which has evolved as a part of third party payer systems…which has led to shortened visits, fewer and shorter opportunities for doctors and patients to communicate, and has punished doctors who would like to spend time doing psychotherapy with their patients.
If we are looking to blame, there’s plenty of it about.
Carping at each other isn’t going to help. Nor can we change the past.
In an early post I had said that doctors need to put ego aside. Well I think patients need to put their need for validation and ego aside as well. I find it hard to accept that many will find my self description of experiences with medication and my illness experience suspect. It is difficult not to be believed. But I can get over it. Because I choose to.
The question is where do we go from here?
This new emphasis on mind-body is interesting, even if it is not at all new, particularly from an eastern perspective. But, what will it mean in how doctors and patients interact?
Can we leave our baggage and mutual distrust behind?
Is it a rehash of the old treatment paradigm? A relabeling of the “same ol thing” with a dash of psychotherapy on the side? Is it what many of us in the corporate world have seen happen when our companies “restructure”, renaming departments, moving desks around, with a bit of sloganeering over top? While business as usual continues.
Or is it a fundamental shift or refocusing?
What supports are there for doctors who want to offer talk therapy or other supports to clients, particularly as this practice has been de-emphasized in training and in an environment where there are still numerous textbooks that state that talk therapy and uncovering therapy should be avoided with bipolar patients in favor of merely brief, crisis focused, strategies that support medication compliance?
What strategies are being emphasized for clients?
How will doctors be supported in dealing with third party payers who are unlikely to want to support such a shift in emphasis? How will patients be assisted in affording counseling services and other non-medication approaches?
How will research be conducted to create metrics that measure these approaches? How will research metrics be constructed given the gaps in experimental measurement present in existing medication trials?
How can we work together to improve side effect reporting systems so that a more accurate picture evolves for clinicians in a naturalistic setting?
How can attitudes be changed in terms of addressing publication biases in favor of research supporting the biological reductionist model?
I think there is work to do. Standing about hitting each other over the heads is not going to get that done.
One cause of suffering is attachment. This can be to objects, but it is more insidious in terms of ideas, attitudes, our own righteousness, and our ego.
I can’t change the fact that I have some collection of symptoms termed bipolar disorder. I can change my attachment to my ideas about how I experienced being a patient. I can change my sense of betrayal that information was not shared with me well. I can change my disappointment of the side effects. I can change my humiliation over experiencing some of these side effects. I can change my need to be “right” about my illness.
I can let go of these things…and I don’t need to invalidate my experience in order to do so. I observe that these things happened. I notice it. I accept it. I observe certain things as a result.
And I focus on how to decrease my suffering further.
One way to do that is to bring the parties involved in the solution closer together in a positive way. I hope you will help me with that.
With respect,
Stephanie
It is nearing beyond repair when you see a patient, referred by their therapist from years of intermittent treatement, who is asking the psychiatrist to evaluate for PTSD and then learn the patient is not going to have renewed therapy at any increased rate of follow up. What the hell is that? PTSD is now one of the biochemical imbalance disorders that doesn’t need much of any psychotherapy!? Is this the new gorilla in the room, therapists who are going to provide services sheerly dictated by insurance approvals?
Maybe it is time for patients to learn a little bit more about the qualifications to be a mental health therapist and what are the standards of care to treat specific illnesses. And maybe it is time for professionals who give a damn about patient care to rise up and call the charlatans who claim to be providers just what they falsely profess to offer.
Anyone reading this who is not outraged to hear a therapist have a patient just medicated for acute features of PTSD, or any other anxiety disorder that is impairing the patient, please leave your diploma and any other certificates of training at the door when you leave at the end of the week.
Unfortunately, don’t read many psychiatrists echo this kind of outrage and advocacy these days at sites like this, do you? But then again, when do you hear words of concern and action from whores and cowards!?
And I learned today that there are psychiatrists charging $500 for an initial evaluation and $200 for med check follow ups in our nation’s capital. For that kind of cost, patients should demand a cure if paying for the services! Anyone reading this who does practice this kind of psychiatric care, please post what are these medications of miraculous impact that restore full function and ability for years of life.
Man, I hate to hear what are therapy rates there!
Dr. Hassman,
Your passion is impressive. I think it is probably not misplaced.
I can speak to the last point directly. I moved to Maine, hence my pseudonym, several years after leaving treatment as part of my own program to remediate some of my symptom triggers. Because I work in IT I have been able to maintain my employment by telecommuting over satellite internet and only visit our corporate office and clients a few times a year. However, I experienced treatment in Northern Virginia in the DC suburbs.
I chose a board qualified specialist who was well regarded in her field who had been recommended to me.
I do admit I was very ignorant about many of the practicalities and dynamics of treatment by a psychiatrist, and it was a very different experience than any I had with psychotherapists.
Although I had good insurance to start out, it did not cover much of my treatment and my doctor did not accept it in any case. I was a cash payer. However, some of her practice, as evidenced by her waiting room and the communications I unavoidably overheard, was Medicare/Medicaid. As a result, her office staff did use the typical billing procedures and appointment set up.
When I went for evaluation in 2005 it cost about $450 as I recall. The appointment was first with a psychiatric nurse who took a history and background, then the doctor joined us, reviewed the notes, asked a few questions and then offered her diagnosis. I believe the overall time between the two discussions was probably a little over an hour, although its been several years.
Med checks that followed cost anywhere from 135 to 180 depending on their length. The nurse did a BP and took information on symptoms and such. Then the doctor would see me for about 15-20 min. In fairness to my doctor, and her busy practice, I believe she did try to give each patient as much time as possible. This was not really enough to do any sort of therapy. She did attempt to spend more time when things were obviously going poorly.
When I went off medication and asked for monitoring there was some consternation over the “non med check” appointment. No one knew what one looked like. The pattern was the same except for the inclusion of a lot of harangue over going back on the meds. I was primarily interested in an external view in case some of the predicted terrible results did occur I wanted someone else who might point them out if I lost all perspective. That didn’t turn out to be necessary but I felt more responsible for having done it.
I sought therapy through the same practice. 45 minutes ran 135 a visit out of pocket.
The rates were similar for biofeedback, which was interesting and somewhat helpful…despite the nurse assigned to me who lost no opportunity to express her disagreement with my decision and the obvious impending disaster that would no doubt result.
Also similar for acupuncture, which was quite an experiment as I have a personal phobia for needles. Nonetheless, it was also helpful but very short acting. I was quite grateful at the time for any uptick in mood even if it only lasted a day or three.
I am grateful for that experience as I later pursued acupuncture through another, somewhat less expensive provider, primarily for lingering pain after I broke an arm in a fall. I would not have tried it had it not been for my doctor’s help in getting over the initial fear of the treatment. It was a different school of acupuncture and that was a learning experience for me as well. I had not realized that some forms of acupuncture worked so differently.
As a side note, the fall occurred after I’d left treatment and I went back to my doctor when my orthopedist suggested I get a neurology consult when he suspected a damaged nerve was causing the continuing pain. I made my appointment specifying that I wanted to see my doctor in her capacity as a neurologist and outlined the issue. When I arrived for the appointment, I found I’d been scheduled for a med check! When the nurse came to take me back for a chat I stopped her in the hall, explained that it wouldn’t be required as I wasn’t on meds and hadn’t been in a year or more at that point. I explained the confusion, or tried to. The nurse’s face took on a horrified expression, she asked if the doctor was aware I wasn’t on meds. I responded that I was quite sure that she was as I had visited for months after for monitoring. I was shooed out into the waiting room. A few minutes later the nurse returned saying I couldn’t have an appointment. Speaking slowly, and loudly, standing in front of my chair in the waiting area she told me I’d have to leave. It was like one of the jokes about foreigners understanding English if you spoke slowly and loudly enough.
After having made arrangements to be off work for this, and waiting for my appt, I went to the counter to see about what could be done. The doctor happened to see me from the other side of the window and asked what was going on. I explained. She gave me a referral to another physician, who was unable to see me as it turned out, and later agreed to see me herself when it was clear I couldn’t find another specialist for at least 6 months. When I related the events to her, she sighed, and interestingly remarked, “Poor X.” (the nurse). I suppose I follow her reasoning to some extent; however, it wasn’t the nurse who was humiliated in the waiting room while staff talked down to them for having the temerity to show up for an appointment they had properly requested.
I will say that the broken arm was a lucky thing in an unexpected way. While the acupuncture did help with the lingering pain, far better than my psychiatrist’s/neurologist’s disastrous trial of Lyrica with me, it had some interesting side effects. After about a month of visits, my sleep patterns changed, my quality of sleep improved, and I found my stressors much more tolerable. It wasn’t an effect I had been seeking at that time in that venue. I can honestly say I had no expectation of the effect. But looking back and at the time, it was a dramatic change I could not account for in any other way. Otherwise my life and particularly my job, were extremely stressful and unsatisfying at the time. My commutes were huge. All the things that contributed to my depression were on “high”…and yet I saw a definite improvement.
It was 65 a visit, I went weekly for a while, and I had to drive all the way across town to get to the provider. Worth every penny and every minute.
The costs when I was on medication were an issue, especially once I lost insurance with my job. Lithium was cheap of course about 10 dollars a month. The Lamictal prescription was 220/month for a drug that ended me up with a massive allergic rash. We tried that one twice because my doctor had been so encouraged by the findings current at the time about anti-depressant effects. She titrated me up on children’s doses the second time once the reaction had cleared. We never saw a true therapeutic effect though despite much effort on both of a part, time, expense, a peculiar dosing schedule, and her effort to find me doses small enough to step up in literally baby steps.
I think we were both rather desperate to believe at that point. I would never do that again though. I felt very sad when I later read that the anti-depressant effects had been somewhat exaggerated in industry presentations.
I think that economics of treatment are not discussed but they definitely played a role in my thinking. I ran up significant costs to attempt treatment. It was a factor in my consideration to end it, although even if we’d had a single payer system at the time I’d hope I would have had the integrity to similarly recognize that the resources to results ratio was not in favor of continuing. I can say that when I spoke to my doctor about cost she did generously offer to extend services for a time on deferred payment. She didn’t offer a plan for how I’d be able to continue past that point making vague suggestions about accessing charity care.
With respect, I feel this is a failing.
When patients ask questions up front, especially about medication duration and addiction potential, they ask for several reasons. First the obvious ones, that they want to know for the sake of understanding. But also, they need to know if they have the resources to sustain treatment over time. My doctor certainly glossed over her medication for life philosophy in our early visits and gave a sunny projection about the non-possibility that any medication she offered would be a problem to discontinue if it ever came to it. I understand this was in aid of encouraging me to undertake treatment and in hopes of assuring compliance.
However, it is not practical. It is disrespectful in it places the patient in a situation they may not be able to maintain financially. Its more or less left up to…we’ll cross that bridge when we come to it.
Again, I understand the concern and perhaps this may be justified in some cases, but it generates a problem.
In my case, I have no living parents, no brothers or sisters, and am unmarried. I had one minor child at the time. I am my own sole means of support. I had no one to back me up when things got to a point where the treatment interfered with my ability to provide for myself. It was either no treatment or charity, the loss of custody of my child, and an inability to provide for myself in one of the nation’s most expensive areas in terms of cost of living.
I can’t say whether I feel more fortunate or more unfortunate. At least my choice was clear, treatment wasn’t helping so a choice to stop seemed reasonably supported in my case. I hate to think what would have happened if I had been one of the lucky third of patients in STEP-BD who benefit! Or the 1 out 5 Dr. Pies reminds us of who see a marked reduction in episode frequency. The decision would have been heartbreaking then, my health versus my ability to parent my child.
I can say when I later decided to discontinue therapy the choice was less clear cut but largely economically based. I enjoyed the supportive and encouraging element of therapy, although it wasn’t much help in terms of addressing my illness in a more direct fashion. What I did know, cold-bloodedly, is that many of my plans to get out of my environment, change my work terms, come to Maine, and eliminate elements of my life that made me worse were directly impacted by a therapy bill that ran into the hundreds each month. I made a decision based on what was likely to get me the healthiest, and had to balance long term, mid term, and short term goals to do it.
In software application design and engineering there are a number of aids to decision theory. I tend to use them even in personal life. One of the most helpful, and difficult tools to use, even in my own discipline is a “no-go” or “failure” criteria. As far as I can tell, psychiatry utterly lacks the application of this tool.
The point of the criteria is that at frequent intervals the designer or team goes back to the initial requirements and checks to see if the design is on track for fulfilling them or not. The resulting decisions may mean refocusing effort back on the primary objectives, eliminating ‘design drift’, or eliminating nice to haves in order to meet budget and schedule requirements.
But, there are points when a team may have to recognize its no longer worth the candle. That for whatever reason the project cannot be accomplished and that to continue pounding away at it will just expend even more resources and time to no good effect. This is a painful and hard decision to make. Teams invest a lot of themselves in the work and really want to finish a product. Even so, there are times when that choice needs to occur.
A concern I had in treatment was that there was no failure criteria. The problem of what to do with non-responders seemed only to be either endless experimentation or indefinite continuation of a treatment that had no apparent positive effect simply to adhere to the maxim that the person should be stable on medication. Personally, I can understand anyone’s quest to get better and to do whatever is possible to get there. What I do not understand is continuing to expose the ones that aren’t getting better to treatment side effects. Those 4 out of 5, the 42% in STEP-BD…aren’t getting better…why do we insist they keep doing what isn’t working for them? the additional 28% in STEP-BD who don’t sustain a remission, similarly why are they expected to continue consuming the medication after it is no longer helpful?
Dr. Pies offers the suggestion that they are achieving other forms of relief not reflected in the study protocols, which may well be the case, but it is not something we can measure well with recourse to the metrics that are evidently used.
But to come back to your point…I think it is highly reasonable to expect patients and their families to make resource decisions based on the economic and personal suffering costs of treatment. It is probably wrong not to take these issues into account when planning treatment with a patient. It is definitely, in my view, wrong to characterize a patient as lacking in insight, dedication to wellness, or commitment for having made a reasonable no-go decision based on cost-benefit versus available resources.
Thanks to all those of good will who have written in. This will be my last posting on this particular blog, and, overall–despite some rancorous exchanges–I feel that the discussion has been worthwhile.
I did appreciate several of “Stephanie
Maine”‘s conciliatory comments in her 9/21 posting, and I agree that doctors and patients need to work together, in order to improve the quality of research, treatment, and therapy. Certainly, my colleagues and I need to listen carefully, and take seriously, many of the criticisms offered in the foregoing comments. At the same time, I hope readers will carefully consider some of the points my colleagues and I make, regarding the treatment of serious psychiatric illnesses.
The philosopher W.V.O Quine once said this about the philosopher’s task:
“We are like sailors who, on the open sea, must reconstruct their ship but are never able to start afresh from the bottom. Where a beam is taken away, a new one must at once be put there, and for this the rest of the ship is used as support. In this way, by using the old beams and driftwood the ship can be shaped entirely anew, but only by gradual reconstruction.”
Psychiatry, as a profession, is in a similar position. My colleagues and I see desperately ill patients each day, looking for relief of their suffering. We have imperfect treatments, and incomplete answers. We should not pretend otherwise. We must do the best we can to help our patients, respect their views, and advance the profession “beam by beam.”
In the end, we are all on the open sea, trying to keep the ship afloat and moving toward the shore.
Best regards,
Ronald Pies MD
Dr. Pies,
You seem to have withdrawn from the conversation, however I hope you will pass by once more to read my reply and perhaps respond to it as well.
I value your article as more balanced than other publications in the psychiatric field.
Allow me to comment, please, on several of the things in your article that struck me as questionable.
You wrote:
“Many patients who suffer from severe depression or anxiety or psychosis tend to blame themselves for the problem. (…) So, some doctors believe that they will help the patient feel less blameworthy by telling them, “You have a chemical imbalance causing your problem.” “
My reply:
Is it scientific or even medically ethical to lie to your patients about their condition? Would a physician do something of the sort? A psychiatric disorder is not measurable biologically nor can it be proven as a medical condition. How is it, then, that it is right to drug people with a psychiatric disorder for the rest of their lives, with dangerous, addictive, mind-altering drugs, to supposedly “treat” (but never cure) their condition which was never proven to begin with?
You wrote:
“It’s a kind of bumper-sticker phrase that saves time, and allows the physician to write out that prescription while feeling that the patient has been “educated.” If you are thinking that this is a little lazy on the doctor’s part, you are right. But to be fair, remember that the doctor is often scrambling to see those other twenty depressed patients in her waiting room.”
My reply:
You portray the psychiatrist as a poor community doctor who is working pro bono around the clock. Psychiatry is far from that. What’s really happening, Doctor, is the psychiatrist is struggling to make more money for every hour of work. Get more patients in, write more prescriptions, fail to allow the patient informed consent (time is money, and who has time to inform the patient of the side effects, when there are “twenty depressed patients in the waiting room”, waiting to be prescribed?), all the while allowing himself to see himself as the saviour of the saddened, offering SSRIs in a sea of anguish. Can there really be a more twisted view of the world? This is a for-profit operation. The pharmaceutical industry is the most lucrative industry in the world, and psychiatrists are its drug dealers. Are you viewing your profession any differently, doctor?
You wrote:
“I certainly can’t tell you the exact cause of your or anybody’s psychiatric illness, but it’s a lot more complicated than a “chemical imbalance”. “
My reply:
Depression can be linked to depletion of vital vitamins and minerals – Do you check that in your patients, before you prescribe them with dangerous and addictive drugs?
You wrote:
“You are a whole person–with hopes, fears, wishes, and dreams—not a brain filled with chemicals!”
My reply:
That is a good note to end your article with. I think Psychiatry, as it is today, being fully bought by the big pharmaceutical companies with their brilliant marketing campaigns – disagrees with you. After all, how lucrative would the business be, if we all believed that our feelings are normal and could be coped with without drugs?
I would like to state here that I know depression, PTSD or any other spiritual or mental condition can be very hard to live with. Psychiatry is offering a dangerous “cure”, which is highly profitable for both psychiatry and Big Pharma. But psychiatry is being highly dishonest when it claims it can help. It can’t. It offers unscientific diagnosis, drugs, electro-shock “therapy” and incarceration, sometimes involuntary.
I think Psychiatry is criminal, as I think the FDA is and the Pharma companies are, when it is promoting mind-altering drugs that are known to cause suicide, suicidal ideation, psychosis, cardiac arrest, etc. Big Pharma, the FDA and Psychiatry are lying to the public and for that, I hope one day they will all be held accountable. I hope they – perhapse even you? – will be stopped before their vision of a distorted future is accomplished.
Allow me to end off with a few quotes:
“We can choose to use our growing knowledge to enslave people in ways never dreamed of before, depersonalizing them, controlling them by means so carefully selected that they will perhaps never be aware of their loss of personhood.”
Carl R. Rodgers, Former President of the American Psychological Association (APA)
“If the race is to be freed from its crippling burden of good and evil it must be psychiatrists who take the original responsibility”
Dr. G. Brock Chisholm, psychiatrist and co-founder of the World Federation of Mental Health
“The family is now one of the major obstacles to improved mental health, and hence should be weakened, if possible, so as to free individuals and especially children from the coercion of family life.”
International Congress on Mental Health, London, 1948
“Society’s excessively moralistic and punitive reactions toward pedophiles go far beyond what I consider to be the gravity of the crime.”
Dr. Richard Garner, clinical professor of child psychiatry, quoted in Insight Magazine, 1999
“There can no more be a “mental illness” than there can be a “moral illness.” The words “mental” and “illness” do not go together logically. Mental “illness” does not exist, and neither does mental “health.” These terms indicate only approval or disapproval of some aspect of a person’s mentality (thinking, emotions, or behavior).
Psychiatrist E. Fuller Torrey, in “The Death of Psychiatry”, 1974
“Nothing has harmed the quality of individual life in modern society more than the misbegotten belief that human suffering is driven by biological and genetic causes and can be rectified by taking drugs or undergoing electroshock therapy. … If I wanted to ruin someone’s life, I would convince the person that that biological psychiatry is right – that relationships mean nothing, that choice is impossible, and that the mechanics of a broken brain reign over our emotions and conduct. If I wanted to impair an individual’s capacity to create empathetic, loving relationships, I would prescribe psychiatric drugs, all of which blunt our highest psychological and spiritual functions.”
Peter R. Breggin, M.D., in the foreword to “Reality Therapy in Action” by William Glasser, M.D., p. xi
I deeply appreciate that the doctor is not willing to shy away from this subject. For me it was all well and good to tell me that a chemical imbalance was the cause of my mental disorder, so as to deflect blame from me as I was highly sensitive to public stigma at the time I first sought psychiatric treatment.
I don’t want to point the finger at only the doctors, though, because Big Pharma raked in absurd amount of money treating chemical imbalances with new SSRIs and SNRIs they were constantly formulating. I especially remember how compelling the Paxil advertisements were for me. Today, an atypical anti-psychotic medicine is just the thing as an adjunct to your SSRI, although it apparently is not so effective in helping with symptoms of psychosis.
The resentment I sometimes entertain over this is that it took me a few years of reading about the mind and the brain, and that two way street between them, before I caught on to the possibility that a chemical imbalance does indeed create the condition of feeling severely depressed, but it is likely that the condition of being severely depressed (by virtue of thoughts and beliefs that control my perceptions) that creates the chemical imbalance response in the brain.
I’m not a doctor or a scientist, and I don’t imagine for a second that my “brain/mind” disorder is so simple as I reason above. WHAT I DO KNOW is that years of suffering and wasting did not have to happen post-diagnosis if the doctor had simply thought me intelligent enough to grasp the complexities necessary for me to understand that, while I was certainly not to blame, I was and am responsible for getting better.
So after years of waiting for the right medicines to be invented, I finally accept responsibility for my therapy and I’m able to enthusiastically engage therapies that emphasize values, goals, commitments, exercises for assessing thinking and beliefs, relaxation practices and even mindfulness meditation and, god damn, wouldn’t you know it? Doing something to solve the problem works. In this life, I guess, if you want something, in my case remission, you’d better make an effort.
It’s a shame so many were “misled”. Sick or not, personal responsibility is all that will see you through because in the end all you’ve got is yourself for the most effective and proactive treatment (the right professional is critical for counsel and perspective).
Do the work even if you are not likely to recover permanently, or have a high relapse potential, because you will at least improve attitude, coping skills, and your outlook, and keep the crushing traps of self-pity and helplessness away. To me the empowerment is incredible, to assert myself over… well… Myself.
I would like to thank Dr. Pies for his time in engaging in discussion with the posters. I recognize that this article was originally a response to a poster on another board asking how he would explain things to a hypothetical patient. I can well imagine that he wrote the article with little realization of the can of worms he was about to open.
From the other posters and my own experience, it is clear we are all in different phases of grieving our experience of treatment. That in itself seems a study worthy phenomenon.
As a comment, I think the difference between patient goals and a doctor’s goals often diverge. In my field we call this design drift and it is surprisingly common and equally destructive. We counter this by frequent recourse to two questions: Is this what the client requested? (What we were originally required to do.) Is this a feature or a flaw?
Often we find that developers get “lost in the weeds” and in geekish excitement decide to spend effort on features that are technically very cool or exciting, perhaps even ground breaking, but which have absolutely no bearing on what we were asked to provide.
As a profession, we too have our arrogance. How dare they not want the cool new thing we just made? Well if we had more ‘sophisticated’ clients they’d appreciate how good this feature is! And worse, we’ll just tell the client what they want as they are too ignorant about technology to know better!
And we too often comment that the best kinds of clients and users are the ones that simply do what we tell them, follow the directions, and educate themselves enough to do so without having to call support every 10 minutes!
I have also learned a lot about writing directions for users, communicating and organizing information in a way that is relevant to their needs rather than reflective of my own view of the system in question.
I can honestly say that my experience in treatment has made me more empathetic and professional in my approach to my clients. Having realized what that felt like in another context to be on the receiving end, I can appreciate that it is a bad idea to echo the behavior in my own work.
An example in BP treatment has been the notion of neuro-protective effects of certain agents. I read some of these studies as this was proposed by my doctor as a rationale for continuing long term a treatment that I could find no other rationale for a the time. It did make for interesting reading; however, it did not stand up well as a justification.
The reason is that, barring any concerns I may have had with the studies and assuming that the claim of an increase in neuronal tissue was supported fully, I could find little correlation between this and a known treatment effect. I understand in theory more should be better, but I had concerns that should this effect be proved out it had obviously not impacted the already known non-success rate of the agents in question.
The doctors are excited by the finding, and I can understand why it piques their interest. But, does it relate to patient goals? Do they want that? And, do they want that when viewed in context with their overall response? Clearly, for a responder this is one lovely added feature! For a non-responder with high side effects it may not tip the scales in terms of decision making at all.
Since, studies have found that there is evidence to support the increase of neuronal tissue as a result of cognitive therapy! So there may be more than one way to achieve this affect if it indeed can be shown to be productive in terms of recovery. This might lead to a different choice in designing one’s treatment approach given that the side effect profile of talk therapy is more or less nil.
An alternative theory: One also wonders what the use of those extra connections are? Is it a good thing or a bad thing to have them at that point in an illness course? Importantly, is there a qualitative difference regarding their formation?
This is something rats and in vitro testing cannot help us understand.
We usually tend to think, less is bad, more is better. What if this decrease in volume is a body’s response to the ‘insult’ of depression/mania or emotional dysregulation? What if, this is the body’s response to provide less volume in which to process what may be an emotional excess?
Mind body suggests that it is a two way connection after all! Why shouldn’t the body adapt to try to put the breaks on in the event of an illness!
So, if we chemically provide more volume and more tissue forms, in absence of a cognitive intervention…perhaps we worsen the problem. The person has more opportunity to lay down “negative tracks”. It would be akin to saying, “I bought more memory for my computer, Yay!” and then filling it with viruses and malware.
Perhaps there is a difference in volume developed as a result of cognitive therapy interventions. Here the new volume develops in the presence of what is hopefully a richer and more positive environment for establishing attitudes and behavior. In this case, if we gain volume as a result, we fill it with “good data”, helpful programs, and processes which are adaptive.
This may somewhat explain why the studies do show a wellness effect in greater proportion for those with cognitive interventions.
So I ask, is that new volume functioning like a callous or is it healthy, vibrant tissue? And, does it matter how the formation is achieved?
Is it a feature or a flaw?
To return to the discussion from other posters…
I think Dr. Pies has been inundated with a lot of negative opinions from us. Have we offered him anything positive to take away? Surely its not the first time he’s heard objections of this sort.
It seems to me that there are a number of patients out there who have left treatment. And, from the sound of it, many of us are managing. Maybe not great, maybe not perfectly, but we do seem to be holding to some level of wellness without medical support.
So, how is that happening? What are your strategies? What have you learned?
Maybe, if Dr. Pies is interested in mind-body and is a position to help suggest content for the ‘mind’ portion of the approach; he might benefit from hearing what could be helpful to others?
What worked for you?
If you want to get better, then take a pill, but if you want to get it right, face the truth.
A line from a Numbers episode a few years ago.
Think about it.
Thanks to all for the additional comments, and to some, for the sincere attempts to bridge the gap between patients and doctors. To those of you struggling with difficult emotional conditions, and equally difficult treatment decisions, I wish you all the best.
Sincerely,
Ronald Pies MD