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).
