Saturday, February 8, 2014

An Obvious Response to "Psychiatry Gone Astray"

David Healy has what I consider to be inconsistent viewpoints.  I have previously critiqued his viewpoint on the "addictive" qualities of antidepressants (they clearly are not) and whole heartedly endorsed his position that pills don't treat depression - psychiatrists do.   He recently posted what I would refer to as a screed written by a Danish internist on (what else?) all of the problems with psychiatry.  The obvious lack of symmetry here is striking.  You won't find a psychiatrist anywhere posting a similar piece about internal medicine, even though it could be easily done and would probably be more evidence based.  In that regard this physician has slightly more credibility that the typical layperson screed against psychiatry - but not much more.  What follows is my point by point refutation of the "myths".  They are mythical in that they are from the mind of the author - I know of no psychiatrist who thinks this way.

Myth 1: Your disease is caused by a chemical imbalance in the brain -

This is a red herring that is frequently marched out in the media and often connected with a conspiracy theory that psychiatrists are tools of pharmaceutical companies who probably originated this idea.  What are the facts?  Psychiatry has at least a century old tradition of researching all possible etiologies for mental health problems.  Psychiatrists were among the first people to look at the effects of social deprivation in orphanages, the effects of acute grief and loss, the effects of psychological trauma, the effects of a full gamut of psychotherapies, and the effects of family and environment.  The biopsychosocial formulation of Engel in 1977 was an advance detailed in Science magazine.  Any comprehensive psychiatric formulation covers all possible etiologies (as an obvious example see Systematic Psychiatric Evaluation by Chisolm and Lyketsos).  In addition there are many clinical methods where the diagnostic formulation is essential for the treatment plan for psychotherapy based treatment.  By definition that formulation would have few biological references.  So the alleged myth fails at the clinical level.

It fails even worse at the neurobiological level.  Chemical imbalance rhetoric always seems to ignore one huge fact and that is Eric Kandel's classic article on plasticity in 1979 in the New England Journal of Medicine.  Certainly any psychiatrist who saw that article has never bought into a "chemical imbalance" idea and I can recall mocking the idea when pharmaceutical companies presented it to my colleagues and I in medical school.  So why don't we hear: "Your disease is caused by plasticity?"  Probably because they gave Eric Kandel the Nobel Prize for it.

Myth 2: It’s no problem to stop treatment with antidepressants - 

Another red herring.  I have trained psychiatrists, internists, family physicians and medical students and taught them psychopharmacology.  A general principle of psychopharmacology is no abrupt changes in therapy and most drug prescribing information suggests that.  I routinely address this issue as part of informed consent and advise people that there may be difficulty discontinuing antidepressants and describe the potential symptoms.  This criticism from an internist has a certain degree of asymmetry to it.  Certainly there are medications prescribed by internists that cause both acute withdrawal and discontinuation symptoms.  My impression is that many adults who see internists are basically going along with life long therapy in many cases for conditions that could be treated by psychosocial measures.  It is quite easy to criticize if you are never faced with the prospect of discontinuing therapy.

Myth 3: Psychotropic Drugs for Mental Illness are like Insulin for Diabetes -

The author here conflates the certainty of insulin deficiency with pathophysiological certainty in medicine and how that correlates with prescribed treatment.  Certainly that is not the case in diabetes mellitus Type II or the recent example I provided with an asthma exacerbation.  In fact the pathophysiology in those heterogenous groups are about as accurate as endophenotypes in psychiatry.  Am I getting prednisone for my asthma because I am deficient in prednisone?  Am I getting it because of some specific pathophysiological mechanism rather than a shotgun approach to shut down all of my inflammatory signalling?  Was predisone prescribed only based on the purported pathophysiological mechanisms?  The answer to all three questions is - of course not.  If the author is really concerned about medication side effects, I can't think of any psychiatric medication that is the equal of prednisone but I am certainly not going to suggest that it should not be prescribed.

Myth 4: Psychotropic drugs reduce the number of chronically ill patients - 

I don't know of anyone who has actually suggested this and from an internal medicine perspective does it make sense?  Here are a few additional comparison statistics on asthma and hypertension for example.  There is a 10% prevalence of asthma in the developed world.  Only 1 in 7 has their symptoms in good control.  People continue to die of asthma possible as many as 1/250 deaths world wide.  In the case of hypertension, 31% of Americans have it and another 30% have prehypertension.  Only 47% have adequate blood pressure control.  There is really not much evidence that medications prescribed by internists are much more effective than what he refers to as "psychotropic drugs" and that is borne out in a previous analysis and my own recent experience with the health care system.

I find this argument also demeaning to anyone with a severe psychiatric disorder who is interested in staying out of hospitals and being able to function or trying to avoid a suicide attempt.  Being able to adhere to that kind of plan depends on multiple variables including taking medications.  It is reckless to suggest otherwise and any psychiatrist knows about severe adverse outcomes that have occurred as a result of stopping a medication.  The author conveniently plugs his book at this point.

Myth 5: Happy pills do not cause suicide in children and adolescents -

The author reveals his antipathy to medication used by psychiatrists here by referring to antidepressants as "happy pills."  I know of no psychiatrist who I have ever met who calls antidepressants "happy pills" and in fact most of us are engaged in trying to find an effective medication with minimal side effects.  David Healy himself describes this as one of the primary functions of psychiatrists.  On the actual suicide issue, psychiatrists goal is preventing suicide.  Suicide is a possible outcome of all clinical encounters and psychiatrists follow this symptom closely.

Saying that happy pills are a cause of suicide is the equivalent of saying that "sugar medicine" (insulin) is a cause of hypoglycemia that harms children and therefore it should not be prescribed.

Myth 6: Happy pills have no side effects -

The author has one legitimate point in that depression screening is not a good idea but in his zeal to criticize everything psychiatric he has to whip that into "happy pills have no side effects".  Of course they do and I have elaborated my clinical method on how to approach that in detail.  He goes on to make an anecdotal argument about single study results versus "what the company says."  In fact, companies have to rigorously record side effects in clinical trials and all of that is recorded in the FDA prescribing information.  Looking at standard FDA reported data for sexual side effects (his example) the number for all SSRI antidepressants is   9-37% and not the 5% figure suggested by the author.  (see page 1684 of Drugs Facts and Comparisons 2013).

Myth 7: Happy pills are not addictive -

This is interesting because of David Healy's confusion on this subject.  It indicates a serious lack of knowledge about addiction because there are no behavioral features of antidepressant medications or animal models that describe these drugs as addictive.  They have no street value and they will not make you high.  The authors comparison to amphetamine is completely off the mark and consistent with his general lack of knowledge of addiction.

Myth 8: The prevalence of depression has increased a lot -

He has to attach epidemiological data on depression in order to attack the argument that increasing antidepressant use is not a problem because of the increasing prevalence.  He offers a sarcastic comment as evidence and misses both the issue of why antidepressant prescriptions are increasing and the real data on the prevalence of depression.  Even if his argument is correct, since 80% of antidepressants are prescribed by primary care physicians wouldn't this be "Primary care gone astray?"

On the epidemiology issue I would encourage a quick look at an actual text on the issue like Textbook of Psychiatric Epidemiology, 3rd Edition.(p 292)  The authors look at 30 national and international studies and do not conclude that there is an increasing prevalence of depression, but that variation is likely due to methodological differences and sociocultural factors. 

Myth 9: The main problem is not overtreatment, but undertreatment -

More sarcasm as evidence here.  I debunked the arithmetic used in this argument in an earlier Washington Post piece.  This is also a huge disservice to people with severe mental illness and addictions in this country who have been thrown out of treatment, received useless hospital treatments, and restricted from medications by managed care.  The primary prescribers of antidepressants (by far) are primary care physicians and it is certainly possible that they are prescribing too many antidepressants.  But don't blame psychiatrists for that.

Myth 10: Antipsychotics prevent brain damage -

More rhetoric.  In this case he is using a research hypothesis and suggesting that this has something to do with clinical psychiatry.  Despite significant obstacles, psychiatric research at the neurobiological level continues and studies on imaging are a large part of that process.  One of the major areas has to do with brain volumes and their implications.  The author presumes he knows what the outcome of that research will be.  He also talks about antipsychotic medication with the arrogance of a person who does not have to treat acutely psychotic people and incredibly talks about these drugs killing people.  In fact, the number one killer of people with severe mental illnesses is tobacco smoke and there is ample evidence that they get suboptimal primary care.

At the end of this refutation what have we learned?  I am more skeptical than ever of David Healy and his web site.  I thought he did good work with his investigation of SSRIs and his analysis of the role of psychiatrists as opposed to medications was accurate.  But I can't ignore the fact that he places this screed on his web site.  He also lists  himself as a "scientist" and this screed contains surprisingly little science.  It is essentially all rhetoric and politics.

It is one thing to ridicule psychiatrists but the obvious concern here is that it stigmatizes people who need treatment especially treatment with medication who are actively denied treatment in the U.S. on an ongoing basis.  The author here uses a familiar dynamic that I have described in the past. He suggests that internists (like the author here) have clearly superior methods or pathophysiological mechanisms than psychiatrists but they don't.  In terms of the accusation of overprescribing, it is well know in the US that the 20 year CDC initiative to control antibiotic overprescribing is a failure.  Some authors believe that this heralds a new "post antibiotic era" where untreatable infections will become the rule.

It seems to me that internists have enough to focus on in their own specialty before criticizing an area that they obviously know so little about.  It also seems that if you claim your web site is scientific, you should probably put a little science on it.  The author here also states that he is affiliated with the Nordic Cochrane Center and I think that anyone who considers the output of that Institute should consider what he has written here and the relevant conflict of interest issues.

George Dawson, MD, DFAPA

Supplementary 1: About a month after this post was completed Ronald Pies, MD came out with an article in the Psychiatric Times entitled Nuances, Narratives, and the “Chemical Imbalance” Debate.  He presents very similar arguments to the ones presented here and concludes that it is time for the critics using this false argument to give it up.  I also like his characterization of "a recent online polemic posing as investigative journalism" and how the "chemical imbalance hypothesis" is used to mischaracterize psychiatry.  He also provides a link to a 2011 article that he wrote that contain the following quote:

"I am not one who easily loses his temper, but I confess to experiencing markedly increased limbic activity whenever I hear someone proclaim, “Psychiatrists think all mental disorders are due to a chemical imbalance!” In the past 30 years, I don’t believe I have ever heard a knowledgeable, well-trained psychiatrist make such a preposterous claim, except perhaps to mock it. "

Readers of this blog have heard seen me say this many times before.  It is good to see these opinions being offered in the more mainstream media.  It is also good to see Dr. Pies taking calling a critic on what is rhetoric rather than reality.  Well done.

Supplementary 2:  I have an updated post on the issue of how medical syndromes and psychiatric syndromes are far more similar than different and how there is a complete lack of criticism relative to psychiatry. (added on September 3, 2015).


  1. Psychiatrists may not be the people who spread these myths, but they are there, and I'd be willing to bet a fishing lure that most people in treatment believe many of these myths. I know that I read them ALL the time on blogs and people will viciously attack a person who says the cause of bipolar or schizophrenia is unknown, but it's not a simple chemical imbalance, etc.

    I can't say I was ever told these myths specifically by a psychaitrist, but handouts I read in psychiatrists' waiting rooms, and packets of information I was given in the hospital clearly stated things about chemical imbalance, the diabetes analogy , that drug treatment works so well that the vast majority of people can live a "normal life" even when they have severe mental illness, so long as they take their drugs etc. and trivialized the most deadly side effects of antipsychotics, along with the less severe ones that merely make taking those drugs intolerable.

    It was rare indeed that a psychiatrist would warn me about side effects from tegretol, antipsychotics, etc. like extreme sedation, weight gain, constipation etc so I could take preventive measures. I was never warned to take birth control in all the years I was on psychiatric drugs, not ONCE. Most of the psychiatrists I saw had excellent reputations. Perhaps they assumed I would know all this stuff which was trivialized in the same reading materials that pushed chemical imbalances as fact, so take your drugs like a good mental patient. It's a fact - mental patients are lied to so they won't stop their meds. If you put drug company and NAMI materials in your waiting room, or your hospital does this, those myths are being peddled as facts. These myths are also perpetuated in bipolar self help books, which are mostly not written by psychiatrists.

    Maybe psychiatrists never believed these things, but if so, few have ever bothered to correct the information from NAMI and other groups, materials that are handed out to hospital patients.

    I think the reason that patients like me were given these lies was in order to give false hope - do ANYTHING to keep those damned mental patient on their intolerable drugs so they don't come back to the hospital. These obnoxious materials poo pooed the whole idea that people go off drugs because they are so constipated they can't go to the bathroom for over a week and are in pain despite chugging laxatives - (hoo hoo, sorry about that pun which happened by accident). Never addressed the issue that many patients can't safely drive while taking antipsychotics. No, the ONLY reason mental patients went off their drugs according to these information sheets was because 1) bipolar patients wanted mania back or 2) bipolar and schizophrenia patients don't know they are sick. NO other reasons ever acknowledged. Maybe things have changed. Oh and I will add that the social workers and therapists sure teach people these things, to get people to take their drugs. Including in groups in the hospital.

    Again, maybe it isn't psychiatrists who say these things routinely. But unless things have recently changed, EVERYONE who works around a psychiatrist, the entire rest of the "support team" (yeah, right, support for mental patients is a myth, and that's why I like your blog, because we do have a lot of severe mental problems in my family but zero help available other than fake help) is perpetuating these myths. When drugs are the only treatment, professionals lie to patients to persuade them to use the drugs at any price. That is truly my experience with psychiatric treatment, and I think what's happened is the tone is changing right now.

  2. Thank you for your detailed comments. The medication information that I routinely had out to people and discuss is from MedlinePlus. It contains all of the black box warnings. most of the side effects as bullet points, and generally more detail than most handouts people get about their medication. Your comments about the support team need to take into account the nature of the support team and the history of what has actually happened. I have never found it necessary at any point in my career to suggest that a person continue a medication that was giving them significant side effects including constipation. I think the commonest reason that people stop taking medications is that they feel somewhat improved and like they no longer need to take them.

    Th critical element in all of this is the relationship with the physician. A person seeing a psychiatrist need to be confident that they are treating them in their best interest and that they can disclose any problems relevant to treatment including medication side effects or lack of positive effect.

  3. FYI, I just wanted to relate that my experience screening patients for admission when I was a resident taught me that, indeed, SSRIs do have a street value. There seems to be the notion, correct or otherwise, that one or more of them intensifies the effects of cocaine.
    I assume, perhaps I shouldn't, that what David Healy means by, "SSRIs are addictive" is that they cause withdrawal effects. I agree that this doesn't make them addictive.

    1. Interesting - I read an article that is somewhat applicable from PLOS a few months ago on how duloxetine inhibits the effects of MDMA largely by transporter protein binding.

      I thought this article was quite exceptional from a pharmacology standpoint because it described new experimental parameters for all three transporters. I don't understand why SSRIs would enhance the effect since cocaine is a non-specific binder but the effects are probably complex across the whole population (for example knockout mice without DAT can get typical reward effects from compensation by SERT).

      The other practical issue is that you can get a month of SSRIs for $4-6 and it does not have the same effect on the economy as a month's worth of oxycodone.

  4. I published a letter to the Archives with Healy on the craziness and circular reasoning involved in the criminal expansion of the "bipolar" diagnosis (Allen D.M., Parry P.I., Purssey R., Spielmans G.I., Jureidini J., Rosenlicht N.Z., Healy D., Feinberg I. “BRIDGE study warrants critique.” Archives of General Psychiatry, 69 (6), pp. 643-644, 2012.), but then he goes off with his truly uninformed nonsense about antidepressants. Marsha Angell, the Pharma critic I used as an extensive reference in my last book, also went insane when talking about antidepressants. These people obviously have never taken careful histories to see which clinical pictures are likely to respond to antidepressants and which are not, and followed patients put on the drugs closely over time, or they would not spout this nonsense. You can almost rule out placebo effects because the drugs don't work right away, and of course you have to manage side effects like any other medication and discontinuation syndrome. Are we are own worst enemies here?

    But psychiatrists are indeed part of the problem. I have had too many patients to count coming in telling me that they were told they were bipolar after a 5 or 10 minute interview with psychiatrists in town. Patients are never told they do not need meds but should see a psychotherapist by many of these so-called doctors.

    1. David,

      I understand exactly what you are saying. If you do detailed interviews with thousands of people you will identify subgroups who cannot tolerate some or all antidepressants, some who probably had serotonin syndrome, some who did very well with maintenance therapy, some who noticed marked relief from anger and aggression and various other subgroups. The history has to be detailed and takes me at least 60-90 minutes of interview time. The whole idea about psychiatrists doing "med checks" for greater profit than psychotherapy comes from psychiatrists acting like primary care physicians rather than psychiatrists. If I had to characterize that encounter, I would say it depends on the patient and the physician stumbling upon some words in a brief exchange that could be taken as implicit goals for treatments so that a medication could be prescribed. Not much more than that. Like you I am aware of the fact that some psychiatrists may think they can do that in 10 - 20 minutes and there are many systems of care out there that insist they do it in as short a period of time as possible.

      The problem is that 10 or 20 minutes does not allow for a detailed enough assessment for the treatment of a complex disorder. The response pattern is critical and in fact, determining that on a case by case basis is more important to the patient than the results of clinical trials. Being seen again in 3-6 months is also an inadequate approach.

      Psychiatrists and patients need to advocate for a practice environment that allows for the appropriate level of time to do the assessment and the logistics of how all of those details are recorded in the chart. There seem to be very few EHRs that can produce coherent detailed evaluations.

      When it comes to antidepressants, people seem to think they can say whatever they want and it must be true. They are less limited than Big Pharma in that respect.

  5. Dr. Dawson,
    Anyone who reads your writing should have no doubt that you are a conscientious practitioner. You preserve the honorable biopsychosocial viewpoint codified by Engel 37 years ago — just before DSM-III refocused psychiatry toward criterion-based diagnosis. Like you, I would never have entered this field, nor stayed in it, if it compelled me to engage in hand-waving and dishonesty. You and I know that "chemical imbalance" isn't an explanation, medications should be adjusted gradually, the insulin metaphor applies only in some respects, and so forth. We also know that some of the rhetoric in Healy's post (e.g., "happy pills") is unhelpful and inflammatory.

    I haven't read your whole blog, but many of your posts charge that psychiatry is unfairly singled out, critiqued too harshly, held to higher standards than, say, internal medicine, criticized out of ignorance, and so forth. It hurts me too to read roundhouse condemnation of our profession, for I try, as you do, to imbue my work with intelligence, sensitivity, and common sense. However, I believe we face a choice: to defend our specialty "warts and all', or to defend it while critiquing it thoughtfully from within.

    On the internet, in person at the last APA annual conference, and in my workday conversations, it's not at all uncommon for me to hear fellow psychiatrists "explain" mental disorders as chemical imbalances, to hear severe SSRI discontinuation syndromes (fortunately suffered only by a small minority) waved off as hysteria, potential side-effects glossed over, etc. I agree with Anonymous above that this isn't due to psychiatric malevolence. Some of it comes from the best of intentions, to get the patient the help he or she needs. Ethicists can debate whether the end justifies the means in such circumstances. But some of it also seems to stem from sloppy thinking, or cutting intellectual corners. In my experience there is a lot of that out there, even if you and I are careful not to fall prey to it ourselves.

    I find no contradiction in being proud of psychiatry and of my work — and feeling unfairly slammed by some ignorant critics — while also admitting that the field and a number of its practitioners are apt targets for thoughtful criticism. As you've written, this latter type of criticism best arises within our own ranks. Nonetheless, we need to accept (as you've also written) that everyone has an opinion about mental health, and that our work will forever be scrutinized from without as well.

    1. Steven,

      One of my top concerns is paralysis by criticism. The prototypical example that comes to mind is the argument for managed care by many at high levels in the APA. For many of them, the argument had to do with a chain of hospitals who were “inappropriately” hospitalizing adolescents. Time and time again the managed care proponents would suggest that this is proof that managed care was needed. They would even say, we realize that there are a “few bad apples” but “those bad apple as are why we need managed care”. In retrospect after 30 years the decimation of psychiatric care it seems like a clueless argument, but in those days it was accepted and it carried the day.

      I have no doubt that there are what I would consider to be poor practices in many places and I often argue that some of this is the result of a severely deteriorated practice environment, burnout, and in some rare cases greed. But like my initial post states - my overall experience has been that there is a majority of intelligent and conscientious effort out there that is easily on par with my own. I agree that there are serious problems when we have physicians critical of the field who seem to say that nobody else knows what they are doing - I guess because the rest of us are somehow incompetent or have not experienced the secret handshake. The idea that many of these critics can essentially say whatever they want often in the context of significant conflict of interest and leave a burden for the rest of us to deal with as rhetoric is appalling to me. Where else can you condemn an entire profession and not see a response from any of the practitioners?

      I don’t consider what I am doing here as defending the entire profession “warts and all”. If you are a wart in my opinion you need to reinvent yourself or get out. On the other hand how many “warts” out there are artifacts of the system. When I first started out in the late 1980s, the scandals back then had to do with CMHCs hiring psychiatrists to provide prescriptions for large numbers of patients assigned to those clinics. In many cases that was the employment arrangement. A clinic manager would tell them to see large numbers of people a day. I think a lot of psychiatrists in that era and the subsequent managed care era were blindsided by business arrangements that were passed off as medical practice. Right at this point in time, the APA is supporting what is essentially a managed care model of some sort of psychiatric consultation that does not involve seeing patients. Our professional organization is supporting the ultimate wart. So I am compelled to write about what I think is the correct way to practice psychiatry rather some idea cooked up in MBA school.

      I accept criticism, on the condition that there are standards. I try to write about some of those standards like realistic comparisons with the rest of medicine since I really have not heard many. There is overwhelming evidence that psychiatry is not only singled out, but that psychiatry criticism is a cottage industry that you can make money at. You can’t do that with any other branch of medicine.

      I hope to get the message out to younger colleagues that the biggest mistake of my generation of clinicians was the idea that we had to suffer through all of this absurd criticism and never respond. That was certainly the party line from the APA, even as managed care was being institutionalized and leveraged against the field. In my opportunities to work with residents, I generally experience them as thoughtful intelligent people who all learn how to practice psychiatry the right way. I also teach them how not to make some of the mistakes that I have observed over the years. I hope that includes responding to criticism that is not well intended and is both destructive to the field and the provision of psychiatric care to those who need it the most.

    2. George,
      Forgive my overly formal address (Dr Dawson) last time; I'm still unsure about blogosphere conventions for professional discussions. I agree that external factors have made clinical practice much more challenging in recent decades. Shrink Rap, Psych Practice, and my own blog have recent posts about the absurd complexities of 3rd party billing in private practice. Also, I worked in a CMHC from about 1993-95 and left exactly for the reason you state: the system didn't let me do a good job. Since then, I've tried to insulate myself from these factors in private practice, while feeling great respect for those (unlike myself) who join organizations like the APA to reform them from within.

      Thus, we agree that some suboptimal practice "is the result of a severely deteriorated practice environment, burnout, and in some rare cases greed." But these factors don't explain the specific "sloppy thinking" I mentioned above, and that Anonymous and Altostrata also allude to. If they or anyone thereby concludes that psychiatry is morally or intellectually bankrupt, please don't count me among them. I believe psychiatry, and the majority of its practitioners, are far more helpful, ethical, and caring than the opposite.

      I suppose I should be happy to give you a "warts argument" to write about. Of course I don't, as I fear you've misconstrued what I meant. I now regret using the phrase. I believe we should give reasonable criticism its due, whether from within or without, and whether or not we can ascribe the cause to external pressures on us. It's valid to note that the same or greater faults exist in other medical specialties, that critics falsely overgeneralize, and so forth. Nonetheless, I feel we should hold ourselves and our colleagues to a very high standard, and personally I don't mind if others do too. In that light, I don't find criticism paralyzing. If the APA does, I would think the fault lies more in the APA than in the criticism.

    3. Thanks - I will modify the argument to call it something else.

      I am not counting you among those who trash the field. I would hope that if you really believed that psychiatrists were as worthless, stupid, and weak as many of our critics portray us you would have quit a long time ago. I know I would have and have pointed out that I would have quit if I was an ineffective as people seem to believe that psychiatrists are as well.

      I am happy to consider reasonable criticism when I see it, but it is rare especially from external sources. It is difficult for me to consider how others are holding us to a high standard when they routinely trash the field, never consider the counter evidence, and have no logical arguments. I hope to illustrate that with the post that was supposed to be on the “warts argument”.

      With regard to paralysis, practically every psychiatrist I have ever met is paralyzed by political criticism. They have no idea how to react to it and it has cost the profession dearly and continues to cost us on a daily basis. Your examples about insurance company exploitation are cases in point. Anybody accusing me of being morally or intellectually bankrupt is not going to be met by a pained expression and silence. They are going to hear that they are clearly wrong and that there are many reasons why.

  6. Can't refute the argument that good doctors practice good psychiatry and bad doctors practice bad psychiatry -- it's a tautology.

    The question is, why are there so many bad psychiatrists? Patients have to search long and hard to find one who even grasps that "tapering" means gradual reduction.

    (Dr. Dawson -- I've written you before about this. If you can recommend any prescribers who understand how to taper people off psychiatric drugs at an individualized rate to minimize withdrawal symptoms, please write me at survivingads at comcast/net)

    I've personally heard the "chemical imbalance," "no problem to stop," "like Insulin for Diabetes," "no side effects" lies from more than one psychiatrist. If they don't believe this nonsense, they should stop saying these things to patients.

    This is still going on, see case reports from the patient's point of view at

    As for antidepressants not being addictive -- this is a semantic argument. The definition of "addiction" was changed in the 1994 DSM IV specifically to exclude the physiological dependency incurred by psychiatric drugs. However, definitions can change. The argument is carried on in O'Brien et al (2006) and Nielsen et al (2012)

    Why everyone picks on psychiatry is easy to answer: There is so much to pick on. The field is riddled with faults. But, most importantly, patients are being injured for no good reason -- psychiatry itself has no process improvement mechanism -- and this creates passionate critics who will not rest until the injuries stop.

    1. The argument as you frame it may seem like a tautology but the argument that you are really making is that it is fair for you to generalize your experience to all psychiatrists and that is a fallacy. It is obviously a lot easier for you to completely discount what I am saying even though I have had direct contact with thousands of psychiatrists and personally taught hundreds of physicians, residents and medical students.

      The idea that antidepressants and addictive medications is an irrational belief that I doubt I will be able to talk out of. I would recommend you abandon at least that part of it because it leaves you with a serious credibility problem even though your remaining arguments are rhetorical.

      The idea that psychiatrists are injuring people at a higher rate than other physicians is completely unsubstantiated but certainly consistent with the rest of your rhetoric. Since other physicians prescribe far more toxic therapies and perform surgery - your statement is unlikely but I would certainly defer to any actual statistics.

      I am currently in the process of using the "Warts Argument" to show the general pattern of arguments that people use against psychiatrists and will post that as soon as I am done.

  7. What percentage of psychiatrists would you refer a family member to for depression? Personally that number for me would be about 30 percent. If it were ophthalmology for anything but a highly specialized treatment the number would be 80 percent.

    The column is essentially a straw man. Find a weak antipsychiatry column and use it to attack all psychiatric criticism. You might as well have picked Tom Cruise.

    1. Interesting spin James.

      The column is a “straw man” but there it sits as definitive criticism of psychiatry on the web page of a renowned critic of psychiatry and nobody as far as I can tell has EVER responded to it. Have you seen the credentials of the author? And you say this is me attacking an antipsychiatry (your term) column? I am the aggressor here? How in the world is this remotely analogous to your hypothetical?

      I guess it is unfortunate that you don't know many good psychiatrists and conversely know way more good specialists than I do . I can tell you that when one of my family members needed a critical procedure there was exactly one physician in that specialty (out of many thousands) that I had her see. That's much less than 1%. I know you will say that is splitting hairs, but it was not from the specialist pool that everyone else in the health plan sees or the people we were referred to – that is the people we were expected to see. For the more common procedures in that specialty it might go as high as 20 or 30% but certainly not much higher and I would use the same figure for primary care. The only specialists that I would consistently rank higher would be Endocrinology, Infectious Disease, and Renal Medicine. In the last group of psychiatrists I worked with (N≈ 35) the number would have been 95%. In my current group that number is 100%.

      Sprinkled throughout my blog is my personal experience with medical care including my current ongoing episode of asthma. I was diagnosed with gout in medical school after seeing an ER doc and several orthopedic surgeons. Luckily the rheumatology department chair at my medical school wrote the book on gout or I still may not have the diagnosis. The curious thing is that in the intervening 30 years, only about 1 in 5 physicians is able to diagnose an atypical exacerbation of gout – even when I am standing in front of them, tell them I am a physician with a known diagnosis of gout, and tell them: “this is gout”. Many of them tell me I have cellulitis and give me a prescription for antibiotics! My personal advocacy was not enough to prevent one physician (who was not a rheumatologist) from sticking a needle into my wrist joint to reprove the diagnosis. He ended up aspirating a chunk of my synovium into the syringe. At least that’s what the pathology report read. But none of those misadventures in primary care would lead me ridicule those physicians the way people ridicule psychiatrists for far fewer reasons. I could go on and on but realize it only my personal experience.

      It is amazing to me how bothered people get when a psychiatrist actually responds to criticism instead of accepting it or turning it on their colleagues. But then again I have expected these reactions since the days of medical school.

    2. That was a good well thought out reply from personal experience. We all have had poor experiences from doctors in other specialities who whiff badly.

      The fundamental problem in psychiatry as I see it is not individual competence but the pseudoscientific core perpetuated by APA that affects psychiatry top-down. Psychiatry may be a science but it is also a business and a lobby. I realize this is no less true of neurology or surgery, but because we are dealing with symptom clusters without markers there is so much opportunity for exploitation, that a higher level of diligence is required.

      I agree with you about anonymous posts, BTW, however, not all criticism is unqualified. Marcia Angell was former editor of NEJM. That's the problem with an appeal to authority in a debate, the other side will always have highly qualified people arguing their point, so it's a wash. I tend to favor highly qualified people over committees for reasons I have talked about in other posts.

      Martin Luther didn't want to destroy the Catholic church, he wanted to end the indulgences and corruption and excessive power of the institutions. That didn't make him anti-Catholic. Pope Leo responded by riding around in an elephant while calling him a heretic and continued to forgive murderers in the name of collecting art. The rest is history. Though the APA clearly isn't as viciously corrupt as the Renaissance church, it is clearly in a state of obtuse denial about overdiagnosis and indulgences and badly needs to be reformed.

    3. I personally have been seriously misdiagnosed by TWO gastroenterologists and, for a different issue, a nurse practitioner working for dermatologists. And then there was my father-in-law when I had just learned to do a physical exam. He was diagnosed with a muscle spasm in his shin and was about to be referred for a whirlpool treatment, which might have killed him. I ran the back of my hand up his shin and felt a hot spot - an extremely simple and accurate test for phlebitis, which is what he had. I sent him back to the hospital and he was immediately admitted. And that was in 1973. It's gotten much worse since.

    4. “I personally have been seriously misdiagnosed by TWO gastroenterologists and, for a different issue, a nurse practitioner working for dermatologists”


      The list is quite endless. During my initial attacks of gout during medical school I was assessed by physicians who actually tried to convince me that I sprained my ankle while sleeping! Upon further referral I was casted in 2 separate walking casts and given acetaminophen with codeine. That is useless for a gout attack. The eventual diagnosis was stumbled upon when one of the doctors asked my wife to leave the room so he could ask me if I might have contracted gonorrhea. Just to make sure they decided to aspirate the ankle joint and I insisted that it be sent to rheumatology.

      The sheer number of women I know who were told that they had shoulder pain from carrying their handbag on that arm when in fact they had referred pain from carpal tunnel syndrome is incredible. But the real show stopper – a family member with intractable ear pain being treated with serial antibiotics. She was in pain and told she needed another antibiotic. I told her to see ENT who got the appropriate imaging study and diagnosed a growth hormone secreting pituitary adenoma wrapped around her right internal carotid artery. To highlight further errors, the radiologist reading the film missed it and it was picked up only by the perceptive ENT physician. The functionality was determined by Endocrinology. After it was removed her intense ear pain and many other symptoms vanished.

      The point here is not to bash our non-psychiatric colleagues, but to point out that the diagnostic process in medicine is difficult and mistakes are made. For 20 years I taught a course in medical diagnostics to medical students that focused on recognizing common biases that lead to diagnostic mistakes and there are many. Anyone who has contact with the medical system knows this. They just suspend reality when they have to overidealize our colleagues in an all out effort to make us look bad.

    5. “I agree with you about anonymous posts, BTW, however, not all criticism is unqualified. Marcia Angell was former editor of NEJM. That's the problem with an appeal to authority in a debate, the other side will always have highly qualified people arguing their point, so it's a wash. I tend to favor highly qualified people over committees for reasons I have talked about in other posts.”


      Some of the power of philosophy is that there needs to be an underlying logic to things. Some of the highly qualified people like Marcia Angell can clearly be wrong. There is a site right now that has an article posted about conflict of interest and the DSM-5 that appears to ignore what the authors say in their paper about some of the many limitations of their analysis (regarding alleged conflict of interest among DSM-5 Task Force members and the drug industry:

      “…our metric for assessing independence in clinical decision-making (DSM panel members and PIs financial association with the industry) is an indirect measure and thus no conclusion can be drawn about actual bias in decision making”

      They go on to say:

      “Moreover, the complexity of the debate over FCOI and the potential for bias is compounded by the fact that trials are commercially funded often report negative findings. For example, researchers found that half of the studies on the efficacy of antidepressants failed to show advantage over placebo and over older tricyclic compounds even though many of these were industry funded.”

      Industry financing and clout also does not prevent the FDA from pulling drugs from the market irrespective of the financing.

      Despite those significant qualifiers and lack of any real evidence it is advertised differently in the title of the article and it doesn’t play that way in the press or on any scandal mongering web site.

      Regarding your point about lining up experts to make anything look like a wash. I would first point out that if psychiatry could get to the point where we were at a wash, that would mark tremendous progress against decades of irrational arguments from our detractors. The second thing that comes to mind is a term I first encounter in freshman philosophy and that word is sophistry. An esteemed philosopher recently told me:

      “Unfortunately, many people use public forums as a soapbox for practicing sophistry. You won't ever beat them head on...they like the sound of their own voices too much. Every statistic you throw their way will be countered with a statistic of their own that supports their perspective.” I agree completely with this perspective but think that there is a way to beat sophistry, by consistently pointing out the fallacies.

      You will get no argument from me on the need for APA reform but I think we mean different things. My perspective is that we have reached the limits of the DSM and what is done with is academically interesting but that doesn’t translate well to what clinical psychiatrists do every day focusing on a very narrow range of DSM diagnoses. It doesn’t matter if they are categories or dimensions. I think the reform needs to occur at the level of the big tent political philosophy – in other words compromises to optimize membership by bringing in people who really have no interest in practicing psychiatry. People with business interests and people who want to advance themselves by managing the rest of us. I would not hesitate to redefine the ethics of the organization as the contract and plan of care that always starts with the physician’s personal assessment of the patient. The MOC situation is also problematic.

  8. I had a former psychiatrist tell me I had a disease just like diabetes, that it was a chemical imbalance, etc. I think he meant well, but I think this lead to me believing that I was a helpless victim of brain chemistry, and so I kept waiting for him to balance my brain chemicals. Contrast that with the psychiatrist I have now who never says crap like that. He's thoughtful and wise, and he only says I think this will help, will you try it. He tells me the side effects. No false promises, no presenting it as something it's not. I much prefer my current psychiatrist's approach. It's a lot more honest. I'm no longer waiting around for my brain chemicals to be balanced, I now see things much more realistically, I think. I see psychiatric medication as an aid rather than the answer.

    1. Thanks for sharing this. One of the main issues in establishing treatment with a psychiatrist is that they are responsive to your preferences. In all major guidelines and standards of care "patient preference" is a priority and you should definitely have the experience that you are getting with your current psychiatrist. Everyone needs adequate information, reasonable choices, and reasonable expectations. Taking any medication is a serious decision and it should be reflected the interaction.

    2. I always hated the chemical imbalance dumb down. You hear that a lot in the rehab community and I wish it would stop. Psychiatrists aren't the only doctors who use facile, incorrect explanations to make it simple for layman to understand, but do damage in the process. How many years did we hear that fibromyalgia was a rheumatologic disease when in fact there was zero evidence that this was the case? Where is the antibody marker? Where is the elevated sed rate? Where is the response to steroids? The disorder became such a problem that the man who coined the term eventually recanted it not only as a rheum disease but a disease period separate from the broad category of functional pain/somatic symptom disorders.

      To the poster who said antidepressives are addictive...there is zero evidence for this. Maybe when they are more effective this will be a problem.

      Speaking of which, the disappearance of MAOIs in clinical practice because of rare tyramine reactions is a pet peeve of mine. In selected patients, these are highly effective and there are no comparable substitutes. It's not like SSRIs and SDAs don't have potentially life-threatening syndromes associated with their use. But there are few people advocating for MAOIs because they are off patent. Again, let's always be aware of financial incentives.

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  10. I think explaining depression as a chemical imbalance does a disservice to both the patient and to our profession (which understands this condition better than the simple explanation implies). I think a better way to do it is to explain everything. For example, when I would recommend antidepressants, my standard spiel would be something like this - "Based on everything you have told me I am convinced that you suffer from a conditions psychiatrists call Major Depression. What it means essentially, is that you feel down most of the time and nothing seems fun anymore. There are other symptoms that you've told me you experience, but that is the core. Depression is caused by the combination of your psychological make up and environmental stress acting on what is an underlying genetic or biological vulnerability. We don't really know which genes, but we know that there is an underlying genetic vulnerability. However, you do need the stress and the psychological issues on top of the biological vulnerabilities to get depressed. Irrespective of what factors are precipitating the depression, we also know that ultimately, as a final step in the process of becoming a person suffering from depression, all the symptoms are the result of abnormal function of certain certain chemicals called neurotransmitters that nerves use to talk to each other. As a result, antidepressants, which can help normalize the function of those neurotransmitter systems can be a useful tool to help improve the depression relatively quickly. However, I will also be the first one to tell you that it's unlikely that you will experience lasting improvement in depression without getting into talk therapy. The meds are effective only as long as you take them; the effects of therapy last well into the future. So I strongly recommend therapy in addition to medication, though we should get started on meds sooner rather than later. What do you think?"

  11. I think it is a reasonable approach but would caution that medications do not necessarily normalize neurobiology. For example you can demonstrate a 15% in increase in presynaptic DAT in people who take stimulants for ADHD.

    I see the discussion in an informed consent context like most things and the need to give people the information they need to make their own decisions. In many cases present with a lot of preconceptions, they may even want a specific medication based on the experience of a friend, family member or their own past experience. They may want no information at all knowing that they might develop or obsess about any side effect that they hear about. Agree completely that they need to hear about the therapies that work especially the ones that work better than medications. There are always people looking to get treatment in the shortest time possible and who have been to therapy and they can often benefit from hearing that there are other therapy options.

    1. If you mean his lines about there not being a "chemical imbalance" in the first place and a "chemical imbalance" needing to be induced so that psychiatrists can get patients dependent on medications and create chronic conditions who knows what he is talking about? For someone who is critical of the "chemical imbalance" he certainly seems to use it as an explanation. The changes I pointed out are right out of synaptic plasticity and it might be a useful read for anyone concerned about how things actually happen in the brain.

    2. I will leave it up to Dr. Raina to explain his position and whether he uses chemical imbalance theory in the manner that it is pejoratively used in the original blogpost. If there are any psychiatrists out there who believe that I would suggest they update their knowledge base. Clearly I didn't amend anything because I did not know what you were referring to.

    3. I liked most of Dr Raina's spiel however would add a few points. Firstly we know depression to be a whole body disease (more properly syndrome with multiple subtypes) with evidence of hormonal, metabolic and immunological dysfunction. We know it kills people, increases the risk of other diseases and causes marked disability. Secondly I discuss evidence on monoamine dysregulation (considerable evidence of thiis including altered serotonin metabolism in those who attempt and complete suicide as well as findings on noradrenaline and dopamine despite Dr Gotsche's glib and nihilistic line). Thirdly I discuss the evidence on the neurotrophic findings in depression and it's treatment. Finally I go on to explain a range of treatments - exercise, lifestyle modification, psychotherapies, antidepressants, lithium, and brain stimulation.

      Since I run a brain stimulation unit I see a concentrated core of profound depressive illnesses - psychotic, bipolar, catatonic, melancholic depressions are common. I often discuss the strengths and shortcomings of pharmacotherapy with my patients as well as the evidence for neurotrophic response to exercise and social engagement. Good clinical care including phase appropriate psychotherapy to help people become skilled managers of a chronic/recurrent illness is what I hope to offer.

      At the core of Dr Gotsche's argument is the disempowering and stigmatizing notion that clinical depression is not a brain disease and that people should not trust the many bright and educated medical specialists who treat it. He is somehow able to discern this better than all these folk who are dismissed as either corrupt or willfully blind to his amazing insight (most definitely an ad hominem attack). He is not qualified to make this argument and shows extraordinary either bias or ignorance in his interpretation of the literature.

  12. Nice to see David Allen on here. I haven't been on his blog in forever. He's a fun writer.

    Seeing him on here also reminded me that psychiatry is very confusing. For instance, David does not believe in Bipolar 2 (he thinks it's actually Borderline) or adult ADHD. That is his right. But there are many pdocs who believe in both. I have had a laundry list of diagnoses. Pdocs have thrown out diagnoses, added new ones, thrown out the new ones, gone back to old ones and tacked on a couple more. Ugh. It all depends on what their own personal theories are. I think this problem, combined with myth spewing, creates some frustration in people.

    A personal anecdote: I'm probably one of the ones David would diagnose as Borderline. I had a couple of pdocs say they diagnosed Bipolar 2 and then later reveal they actually thought I had Borderline. I asked another pdoc why they thought this (he didn't think I was Bipolar or Borderline) and he started to laugh. He said it's because I'm telling them that I have seen a lot of different pdocs since my childhood and have been on a lot of drugs. And when some pdocs see that profile they diagnose Borderline (encoded as Bipolar in my case). To David's credit, he would have left out any mention of Bipolar.

    Again, just saying, sooo frustrating.

  13. The problem with Paxil/Seroxat and related medicines is not even the severe side effects while taking them. Many medicines have side effects, and using them is always a tradeoff between the desired effect and the undesired side effects.
    With "normal" medicines, after quitting them, the desired effects as well as the side effects will go away.
    But not with Seroxat, the devilish effect of this drug is that you cannot quit it because of the horrific withdrawal which renders you unable to function after quitting, which is totally unrelated to the "original condition".
    Moreover, manufacturer GlaxoSmithKline has deliberately omitted this gruesome effect from the leaflets, and even mislead patients and doctors by putting "These tablets are no addictive" in the leaflet without explaining their defintiion of addiction which differs greatly from the definition from the man on the street.
    Al those countless people who are hooked on Paxil/Seroxat and unable to stop would probably never have taken it if this was honestly discussed with them! But for GlaxoSmithKline it is money above human life.
    I suffered total hell after getting off Seroxat and was disabled for more than 6 years due to the withdrawals (which could last 3 weeks according to GlaxoSmithKline, the biggest lie in medical history!!!) No one, not my GP nor my pharmacist, warned me that this could happen.
    I can honestly say that Seroxat withdrawal almost costed me my life while I had no single psychical of neurological problem when I got it prescribed.
    I will not condemn all psychiatrists but as long as psychiatrists will use the "guidelines" of these immoral and dishonest companies, they will do more harm than good.

    1. You have touched on something here. The paroxetine was prescribed by your GP, your pharmacist had no additional information, the medication was approved by the regulatory body in your country of origin and yet you are blaming psychiatrists? From what we know about antidepressant prescribing the vast majority of antidepressants are prescribed by primary care physicians and not psychiatrists.

      I don't know what guidelines you are referring to. In the US, the FDA approves all prescribing information that is typically available as the FDA package insert or in medical information on prescribing.

      I can tell you that I have prescribed paroxetine for a handful of people or less and certainly none in the past 15-20 years. I noted early on that it was a problematic medication in terms of the way it potentially effected the metabolism of other medications.

      In a more functional system of pharmacosurveillance, the severe syndromes experienced by you and others would be incorporated into update prescribing information by the regulatory body in your country. The FDA for example might list it as a warning to prescribing physicians.

    2. Dr. Dawson, you are right that I got the paroxetine from my GP and not from a psychiatrist. Though later, when the withdrawal started to hit, I did actually visit three different psychiatrists but none of them told me what I deserately needed to know, that my nervous system had become dependent on the "non addictive" drug and needed to be tapered off as slowly as necessary.
      From many other people I hear the same. This is not the primary fault of the psychiatrist but of the company whi withheld this crucial information.
      As early as in the late nineties, the disastrous withdrawal effects of paroxetine became well known and around 2002, a whole series of documentaries on the British BBC was broadcasted under the title "Seroxat Taken on Trust". But the FDA did nothing and I got it prescribed without any warning between 2002 and 2007.
      Also my pharmacist as well as a psychiatrist told me that after so many years, the drug was "out of my body now for long", effectively dismissing my still torturous withdrawal symptoms as nonsens and not hindered by any knowledge about SSRI withdrawal, which not stops, but starts after withdrawing from the drug.

      I did report my experience to the regulatory body as you suggest, only to get back a standard answer that they will not take any action upon it.
      By the way I am glad to read that you do not prescribe paroxetine anymore and are aware of its dangerous and toxic effecs, because it can be a one-way ticket to hell and beyond when one tries to get off it.
      But I am shocked to see that the same stuff is now marketed under a different brand name (and a slighty lower but still very dangerous dosage):
      Also approved by the FDA so I wonder whether they have learned much from the Seroxat scandal..

    3. Klaas - as I have pointed out may times before psychiatrists are barely functional at this point. In the US they are completely ineffective against the FDA, the federal government, state governments and the managed acre industry. I don't know what country you are in but there are independent bodies that are supposed to advocate for reasonable use of medications including treatments like the NICE collaborative in the UK. Most people do not understand that psychiatrists are very peripheral to this process.

    4. " Not a lot has changed since I was prescribed Seroxat 15 years ago. The same drugs are being prescribed, people are still not being adequately informed and these drugs are harming people in their droves. There is little difference in lying and failing to tell the truth and psychiatry has perpetuated myths about psychiatric drugs, psychiatric illnesses and psychiatric treatments for decades. The only difference nowadays is people can research for themselves on the internet and find information."

      I could not figure out how to respond to your post with the Blogger software interface so I cut and pasted it her. It s funny how some people acknowledge the facts as they are and other don't. I posted my 20 year plus position on paroxetine. It is one that I have passed along to a generation of psychiatrists. The psychiatrists in my groups rarely prescribed it. And yet here you are claiming that psychiatrists are creating "myths" about psychiatric drugs. I would invite you to pull up one of those myths anywhere on this blog. I will also echp my previous posts about the regulatory bodies who investigate these problems and are responsible for drug safety. The current FDA approved package insert for paroxetine has 13 references that anyone can look up. I post the first one here as an example only:

      "With this regimen in those studies, the following adverse events were reported at an incidence of 2% or greater for PAXIL CR and were at least twice that reported for placebo: Dizziness (11.9% versus 1.3%), nausea (5.4% versus 2.7%), nervousness (2.4% versus 1.1%), and additional symptoms described by the investigator as associated with tapering or
      discontinuing PAXIL CR (e.g., emotional lability, headache, agitation, electric shock sensations, fatigue, sleep disturbances) (2.4% versus 0.3%). These events were reported as serious in 0.3% of patients who discontinued therapy with PAXIL CR ...."

      So there you have it. The reality is that none of the psychiatrists I know are prescribing paroxetine and in the USA it is a a $4/month drug a WalMart:

      So it would seem to me that any rational person would see that the beef here is with the FDA and the pharmaceutical company. You can blame psychiatry or psychiatrists all you want, but it should not be too surprising that nothing changes in the direction you want it to. Psychiatry has no leverage with either pharmaceutical companies or the FDA and if you search FDA on this blog you will see I am a critic myself.

      So if all of the anti-paroxetine people in the world organized and lobbied the FDA or the equivalent bodies world wide - you would be taking focused action.

      If paroxetine was pulled tomorrow - there is not a psychiatrist I know who would miss it.

  14. Nothing like a serious lack of scholarship and a conspiracy theory to denounce an entire field. Despite your allegations of the prescription pad conspiracy - I completed my residency over a decade later with more psychotherapy training than most therapists.

    But thanks for the interesting quotes for my Heat Map.

  15. Dr Dawson,

    Why are doctors so eager to dismiss side-effects of medication, in some cases permanent?

    I know at least 3 thousand people, including me, who have developed PSSD (Post SSRI Sexual Dysfunction) after taking SSRIs. Doctors just dismiss as "psychological" and are not even open to that possibility. How likely is it that thousands of people have genital anesthesia, ED, etc, for 5, 10, 20 years after stopping SSRIs and SSRIs having nothing to do with it? This man, for instance, hasn't had an erection in decades (

    Saying "there are very few reports of PSSD if we take into account the millions of people who have taken antidepressants" is ludricous, as the people complaining from PSSD are usually sent away with a "psychogenic sexual dysfunction" diagnosis and 99% of those cases ARE NOT reported to any regulatory agency. If doctors don't report them how could there be? Most patients don't even know they can themselves file an ADR.

    For example, a study on statins' side effects concluded that "Physicians were reportedly more likely to deny than affirm the possibility of a connection. Rejection of a possible connection was reported to occur even for symptoms with strong literature support for a drug connection, and even in patients for whom the symptom met presumptive literature-based criteria for probable or definite drug-adverse effect causality." (

    If you sincerely care about your patients (and ex patients), as I believe you do, I ask you to do something in order for someone to start research on the subject.

  16. "Why are doctors so eager to dismiss side-effects of medication, in some cases permanent?"

    Search "side effects" on this blog and you will see differently. Medication is always an informed consent issue with me. The supposes the patient has enough information about potential side effects of a drug and they are willing to risk those side effects to take it. I think that everyone should be informed of the possibility of SSRI and SNRI and TCA withdrawal. After all, I prescribe drugs that can result in complications including death and people need to know those risks.

    I think doctors may be eager to dismiss side effects because they are eager to think that they are doing something positive and they can't bear to think that they may be harming a patient they are trying to help. That combined with the fact that there is so much information to learn places the emphasis on potential therapeutic effects rather than side effects. Most physicians don't realize that managing and minimizing side effects is the most important part of the job until after they are out in clinical practice and realize the extent of the problem with medication side effects.

    That all sounds well and good but I doubt that will even be enough. I base that on a number of TV ads for medications where the announcer rattles off "....a number of side effects including death." Because these are multimillion dollar ad campaigns for a very expensive medication and there are a lot of these ads, that suggests to me that even the likelihood of death is not a deterrent to people with a particular problem. That says more about the disease than the medication.

  17. Dr. Gordon,

    I don't publish comments greater than 6 months from the original posting date.

    If you are interested in a reply - send me your email address to

    If not - cheers,


  18. Dear Dr Dawson,
    Is this your own rule? So much for openness and challenging myths.

    What I will do is include my response to your blog on a blog of my own.

    I wish you all the best. Kind wishes from Scotland.

    Dr Peter J Gordon

    1. Of course it is my own rule. I fail to see how a post that is by your own admission wildly speculative and rhetorical is "openness and challenging myths"

      Establishing your own blog is certainly your prerogative.

      You might want to start with something that is remotely accurate - but again that is also your prerogative.

      You can count on the fact that I have survived attacks in the past and will still be here.

      George Dawson, MD, DFAPA

    2. For any interested parties the moderation policy for this blog is posted here: