Has Psychiatry Chosen to Ignore the Hippocratic Oath?

Psychiatrists are doctors who take the Hippocratic oath to

apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.

and

remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.

Why then do they persist in prescribing drugs that have been shown to have little or no benefit above placebo but expose their patients to the risk of suicide, homicide, mania, psychosis, cardiac arrest, diabetes, dementia and a host of other adverse effects?

Why would they do with without first conducting full physical health checks and trialling talk therapies?  Why do they write prescriptions within minutes of meeting patients and fail to advise them of the risks and possible adverse reactions of the drugs they are prescribing? Why do they meet with patients solely to write repeat prescriptions rather than to listen, empathise and offer support?

I have never believed psychiatrists wake up in the morning planning to do harm to their patients. I don’t think they chose this specialty so they could increase suicide and obesity rates, cause brain shrinkage and cognitive deficits. What then motivates them to prescribe drugs when studies show that talking therapies are  equally effective without carrying the health risks of psychiatric drugs?

Why for example, is New Zealand reporting that the prescribing of anti-psychotic medication among 10 to 19-year-olds has risen 47% since 2007[1] when studies show psychotherapy is as effective in reducing depression and mania scores as quetiapine[2] without the suicidality, seizures, tardive dyskinesia, diabetes and other adverse effects of the drug, which is not even approved for children in New Zealand?

Why is the New Zealand Medical Journal reporting that quetiapine is the most commonly prescribed off-label agent being the first choice of 94% of doctors surveyed, more than half of whom are prescribing the drug off-label every week and only 25% of its prescribing in an inpatient setting being for conditions for which it is approved in New Zealand?

I believe the answer, at least in New Zealand, has little to do with medicine and everything to do with job protection.

The need to balance budgets has resulted in new business model in mental health services. One where non-medical professionals are employed to fill roles and undertake tasks previously the province of psychiatry. As a result, prescribing is the only role psychiatrists have within the mental health system which they alone have the qualifications to conduct. Under the new model where assessment, diagnosis, treatment planning and delivery are undertaken by a raft of other professionals,  it is all they do, and is their only competitive advantage over psychologists, social workers, occupational therapists and the other professional groups employed in the New Zealand mental health system as Key Workers.

The simple fact is that If not for their role in prescribing drugs, psychiatrists would be redundant within the system.

If you doubt this, and want to argue that psychiatrists play a critical role in assessment, diagnosis and treatment planning look at the figures on the vacancies for psychiatrists in New Zealand Child & Adolescent Mental Health Services (CAHMS) and the increasing number of kids who are under the care of mental health services and not assigned to any psychiatrist. Check some patient files and see who conducted assessments, recorded diagnoses and developed treatment plans.

Primarily, psychiatrists prescribe unnecessary and harmful  drugs because if they didn’t, there would be no role for them in mental health services. They do not tell patients and their families about the risks or that the drugs are being prescribed off label because it may deter patients from consenting to taking them and thus to providing a role for psychiatrists in their treatment.

When the service you are delivering and product you provide has no benefits to those receiving it, you have three options. You exit the market, reposition yourself within it or artificially manufacture demand. Psychiatry has chosen to do the latter, to create a perceived benefit for their product and secure their position as the preferred or only supplier.

In the case of antipsychotics, psychiatry has persuaded the population that bi-polar disorder is endemic and that drugs are the solution.

The Blackdog institute in Australia is an example of how they are doing this. The government funded site includes a self test for bi-polar disorder[3] which asks those completing the test questions to establish depression and then whether they have had periods where they

Feel more confident and capable

See things in a new and exciting light

Feel very creative with lots of ideas and plans

Become over-involved in new plans and projects

Become totally confident that everything you do will succeed

Feel that things are very vivid and crystal clear

Spend, or wish to spend, significant amounts of money

Find that your thoughts race

Notice lots of coincidences occurring

Note that your senses are heightened and your emotions intensified

Work harder, being much more motivated

Feel at one with the world and nature

Believe that things possess a ‘special meaning’

Say quite outrageous things

Feel ‘high as a kite’, elated, ecstatic and ‘the best ever’ Feel irritated

Feel quite carefree, not worried about anything

Have much increased interest in sex (whether thoughts and/or actions)

Feel very impatient with people Laugh more and find lots of things humorous

Read special significance into things

Talk over people

Have quite mystical experiences

Do fairly outrageous things

Sleep less and not feel tired

Sing

Feel angry

The developers of the test state that while the DSM-IV requires these ‘symptoms’ to have been present for four days, the test reduces this to one day. As if arbitrarily altering the DSM requirements is not enough to widen the net and capture more customers, the website advises that even those who score below the cut off line may suffer bi-polar and are advised to see a health care professional to discuss their results.

An evaluation of this self -test showed that 65.1% of those who undertook it returned scores indicative of a probable bipolar disorder, with 89.3% being moderately to severely depressed. It is noted that sixty percent of the group would not have met formal DSM-IV criteria for bipolar disorder as their ‘highs’ lasted less than the four-day minimum duration imposed for hypomania. While only 65.1% had scores indicating bi-polar, 70.6% indicated they would visit a health professional to clarify the self-test result. As an advertising tool, the test performed outstandingly with 93.7% of those using it saying they would recommend it to someone if they suspected they may have bipolar disorder.[4]

The Black Dog Institute advises it “is at the forefront of research into therapeutic benefits of drug treatments, and works closely with pharmaceutical companies.”

In New Zealand the focus is on depression with government funded Depression.org promoting a self-test for depression copyrighted to drug company Pfizer and advising that “Anti-depressant medicines can help to correct changes in your brain involved with depression.”

While the evaluation of this programme known as the ‘national depression initiative’ is pending publication, the fact that the Cabinet appointed Welfare Working Group reports that in December 2009, 41% of New Zealanders receiving a Sickness Benefit and 29% of people receiving an Invalid’s Benefit had psychological or psychiatric conditions listed as their first condition, gives an indication of its success.

With the advent of mental health services employing other professionals to take on roles traditionally conducted by psychiatrists I wish that psychiatry had chosen to reposition itself, perhaps as the specialists in the interface between physical and mental health, rather than articifically create demand for drugs with little efficacy but proven harm. Identifying and treating medical disorders that affect moods and behaviours is an area that receives little attention and for which there is good empirical evidence and where psychiatrists could have upheld their oath.

Securing competitive advantage by partnering with drug companies to ensure demand for prescribing increases and psychiatrists are secure in their employment in the new business model is a disaster for patients in the short term and unsustainable for psychiatry in the long term, given the evidence of the harms these drugs cause.

By making the choices it has, prioritising job security over patient health and safety, psychiatry  breaches the promises within the Hippocratic oath. They over-treat their patients with drugs that do more harm than good and fail to recognise the benefits of warmth, sympathy, and understanding above drugs. I’m sure I’m not the only one who wonders how they sleep at night.