I decided to end the year on a less intense but serious
note about antidepressants. I am currently working on some posts on biological
psychiatry most notably on the hypothalamus. When you see that posted it will
hopefully contain some licensed graphics, numerous worthwhile references, and
it will be the first post on this blog where copy-paste function will be
blocked. I have seen the results of not
blocking my blog content and many people pointed out that it is just copied to
another site and not referenced. In what had to be a worst case scenario, I was at a conference where an academic used my custom graphics in his PowerPoint presentation without referencing that they were from this blog. Hopefully
those days are over.
But in the meantime a few comments about the war on
antidepressants which is really a war on psychiatry. There are numerous posts
on this blog refuting some of the published material but I want to speak about
what happens at the clinical level without all of the academic references and articles. I decided to post this because antidepressants
have been heavily politicized over the years. The initial rhetoric was that
psychiatrists were prescribing them because they were being corrupted by
pharmaceutical companies. The next step was to suggest that antidepressants
were highly toxic medications for one reason or another. When both those
criticisms were obviously not valid, the next step was to suggest that
antidepressants simply don’t work at all. In social media this takes on a tone that discourages people from treatment. Psychiatrists are shamed for prescribing these medications and patients are shamed for taking them. Why would a rational person take a medication that did not work?
There have been slight modifications along the way. A good
example would be the “chemical imbalance” theory that has been heavily
criticized and attributed to psychiatry despite the fact that no
psychopharmacology books contain this reference and the discovery that the term
is an advertising meme from the late 20th century. Some of the
critics like the “critical psychiatry” movement came out with an actual
position paper that proposed medications basically work because of side effects
rather than any primary therapeutic effect. That is an incredible position to
maintain and that may be why nobody pays attention to it. The critics of
antidepressants and psychiatry are very vocal and if they are not complaining
about psychiatric expertise or medications they are complaining about criticism
they might receive. But the overall tone of their arguments illustrates that they have nothing positive to offer. Many of these critics have the luxury of not treating people with severe psychiatric disorders. In some cases that extends to denying that these disorders exist.
One of the critics complained about being “gaslighted” for some of criticisms. This is more than a
little ironic for several reasons. The standard positions of most antipsychiatrists is the very definition of gaslighting. That position is to basically create a hostile environment that denies the legitimacy of psychiatry and psychiatric practice and treatments. I have received hundreds of posts to this blog that never see the light of
day. Some say (in many posts) that I am a hack who should not
be treating patients. They claim I am an agent of the pharmaceutical industry (search all of the databases and you will see that I have not accepted as much as a nickel). They tell me that my research is poor and I have very
little understanding of the literature. Some have suggested that they would like to see me physically assaulted. One of them went so far as to hide the
fact that he was a writer for a major anti-psychiatry blog until the last
possible moment. I think he was really expecting that I was going to publish
his post and name so that everyone on that website could have a good laugh at my expense. These
critics seem to have a very thin skin and can’t take the slightest criticism
for what are typically outrageous positions.
I could quote all the evidence to the contrary hundred
times but it would not do any good. The dynamic is very similar to other antiscience arguments, like the arguments against vaccines. The average person with a realistic concern
about antidepressants should just be aware of the process at this point. There are a group of people who are out to discredit
psychiatric care and medications that psychiatrists use strictly based on
political agenda that has nothing to do with whether or not medications or psychiatry
works. The lesson of politics is that "the narrative" becomes the truth - particularly if one side "wins." Demonizing a perceived opponent is a common political strategy that may be amplified by social media. This process focused on demonizing psychiatrists and the medications they prescribe can be observed in social media on a daily basis.
There’s no better evidence that psychiatry works than the
fact that we all go to work and see hundreds of thousands of people
every day. Those people come back to see us because they are satisfied both
with the relationship they have, the advice they get, and the fact that their treatment is
effective. That includes treatment with antidepressants. People don't take time out of their day, endure the problem of finding a psychiatrist who can see them and hassles with their insurance company, and follow treatment recommendations if the treatment is not effective.
As I noted in the title - antidepressants are certainly not miracle drugs. About one person out of seven or eight that I see cannot tolerate selective serotonin reuptake inhibitors (SSRIs). About one person out of 15 cannot tolerate any antidepressant from any class. That fact alone points out one of the limitations of antidepressants. Additional patients will get more isolated side effects that create physical effects or affect their lifestyle and they have to make tough decisions especially if the medication is effective. They have to decide whether they want to keep taking it or not. But the clinical truth that you don't hear among the critics is that the majority of people can take an antidepressant and not get any side effects. I know this because, I ask that specific question to every person I see who is taking a medication - every time I see them.
As I noted in the title - antidepressants are certainly not miracle drugs. About one person out of seven or eight that I see cannot tolerate selective serotonin reuptake inhibitors (SSRIs). About one person out of 15 cannot tolerate any antidepressant from any class. That fact alone points out one of the limitations of antidepressants. Additional patients will get more isolated side effects that create physical effects or affect their lifestyle and they have to make tough decisions especially if the medication is effective. They have to decide whether they want to keep taking it or not. But the clinical truth that you don't hear among the critics is that the majority of people can take an antidepressant and not get any side effects. I know this because, I ask that specific question to every person I see who is taking a medication - every time I see them.
A more challenging clinical situation occurs when a patient
asks me to start an antidepressant that they are certain has worked for them in
the past and now they develop a symptom that may be a side effect that they did
not have in the past. We need to figure out what is happening and what the best
plan will be. The more common scenario is the person for whom the
antidepressant does not work completely and we need to figure out how to get
rid of their depression or anxiety.
All the negative talk about antidepressants is designed to
take psychiatrists out of the equation. Nobody talks about the psychiatrist who
is in the room with the patient actively working on and solving all of these problems. The problems that need to be solved from a medical and psychiatric
standpoint can often make up a long list. Pre-existing medical conditions, 5-10
medications that are being taken for those conditions, drug interactions with
any pre-existing conditions or medications, medication side effects, unstable
medications, ECG abnormalities, medical causes of the psychiatric symptoms, neurological problems, significant renal or hepatic disease, and alcohol and substance use problems
are all in that room and all need to be acted on by the psychiatrist and the
patient in the room. If somebody suggests that psychiatrists are doing less than that - take a look at the way psychiatrists are actually trained. The ask yourself why you are not getting the whole story.
And even before we get to that point, there has to be some
clarification of a diagnosis indicating that medication might be useful. There
has to be a diagnostic formulation looking at how that diagnosis fits into that
person’s life and conscious state. The prescription of a medication can’t be a
formula based on a checklist. There are many times when a prescription
medication is not the right answer. Don’t expect to hear that level of
discrimination from somebody who tells you that antidepressants or
psychiatrists are either generally bad or all bad. When you hear that opinion - drill down and figure out what their conflict of interest is.
In my current capacity, a significant number of people I
see have suicidal ideation and many have attempted suicide or are actively
contemplating suicide. Some have survived highly lethal suicide attempts. Most of them have depression and substance use
disorders. I have to figure out the most likely diagnosis out of about 40
possibilities. In proceeding with treatment, my job is to help the person get
well, recover from depression, and recover from suicidal thinking. That is a
complex process and it is not just a question of prescribing medication. What
is said and done in that process is not the same for any two people. I have to
make sure the person is getting well and making necessary changes along the way
to recover. There are many people along that path to confirm that the
treatment is proceeding in a positive direction. This process is one of many
leading to the demand for psychiatrists across the country. Psychiatrists have
the clinical expertise to solve these problems and we are often consulted at
the last possible moment after all of the other attempts have failed.
With any luck it will be a better year ahead. I don’t
expect the anti-psychiatry gaslighters to go away. I do want to reassure
people that psychiatrists are result oriented and we are trained to work
intensely with people to help them get better. If you see suggestions contrary
to that fact - consider the source. If you see someone suggesting that they are
being “gaslighted” by psychiatrists remember what I said about the posts I get
here on this blog. And remember, antidepressants are just like any other medication. They don't work for everybody, but most people who can tolerate them notice a difference. For some people the difference is life changing and it allows them to function the way they used to function. Like practically all medications, the decision to take antidepressants is a highly individual one and a decision that is not made lightly. Most people making that decision are not making it based on what is on social media.
As professionals we take a safe recovery from mental
disorders and substance use problems very seriously.
Happy New Year!
George Dawson, MD, DFAPA
Graphics Credit:
Color gradient during the sunset in Antarctica. Vernadsky Station. Antarctic Peninsula 2008.
By Maksym Deliyergiyev from Shutterstock per their standard user agreement.
Supplementary:
Academic gaslighting?
Of course, it exists. I realize that it is a vague and non-specific term A few examples follow from this blog. Unfortunately,
journal editors either don’t seem to get it or they are too desperate for content to
care.
The Identity Crisis Card: https://real-psychiatry.blogspot.com/2019/11/there-is-no-identity-crisis-in.html
The Diagnostic Heterogeneity Card: https://real-psychiatry.blogspot.com/2019/09/recent-opinion-about-diagnostic.html
The Epistemic Injustice Card: https://real-psychiatry.blogspot.com/2019/07/some-of-greatest-minds-in-psychiatry.html
The Chemical Imbalance Card: https://real-psychiatry.blogspot.com/2019/05/chemical-imbalance-as-advertising-meme.html
The Critical Psychiatry Card: https://real-psychiatry.blogspot.com/2019/05/chemical-imbalance-as-advertising-meme.html
The Antipsychiatry Card: https://real-psychiatry.blogspot.com/2018/08/why-antipsychiatrists-have-it-all-wrong.html
The Antidepressants Are Toxic Card: https://real-psychiatry.blogspot.com/2018/04/sensational-antidepressant-piece-from.html and this recent review.
The Physicians Are Corrupted by Big Pharma Card: https://real-psychiatry.blogspot.com/2017/05/wait-minute-is-psychiatry-less-unhinged.html
The Too Much Neuroscience Card: https://real-psychiatry.blogspot.com/2016/10/the-balanced-rhetoric-against.html
The Psychiatrist Shortage Card: https://real-psychiatry.blogspot.com/2016/08/a-better-analysis-of-psychiatrist.html
The Reductionism Card: https://real-psychiatry.blogspot.com/2015/11/reductionism-is-not-dirty-word.html
The Philosophy Card - written by an expert on Foucault: https://real-psychiatry.blogspot.com/2013/02/moralizing-about-psychiatry-and-limits.html
This Supplementary section was added on 1/2/2020 at 0200. The body of the original post is unchanged.
