September 18, 2010

Mark Foster, DO
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Dear Robert,

I just finished Anatomy of an Epidemic while on vacation.

I am a family physician (and writer) practicing in Colorado.  For years, my practice has been drifting of its own accord towards a distrust of the psychiatric establishment, a skepticism of pharmaceutical companies, a resistance to labeling patients with psychiatric diagnosis, and a lifestyle intensive approach to mental health disorders, emphasizing exercise programs, social support networks, and sparse use of psychotropics.  Thus, your book resonated on a fundamental level with me.

This drift in my practice, based largely on my own anecdotal experiences and reinforced with the scant contrarian news items that percolate down through my mainstream medical texts and journals, has caused significant cognitive discord because, although it feels ethically, morally, and scientifically right to me, it flies in the face of what the Establishment says is the mythical Standard of Care.  A non-drug-based approach to mental health issues also conflicts with patient expectations, and unfortunately, part of a successful primary care practice is satisfying a patient’s desire for a “fix” for what ails them.

In spite of my reservations, I still prescribe or renew SSRIs, benzos, stimulants, and occasionally antipsychotics, on a daily basis.  I am nearly always cautious to tell patients something along the lines of, “The mind has an amazing capacity to heal itself, and so we’ll try this medication for 6 months and then reassess your need for it.”  I give them specific recommendations for daily exercise, daily meditation, and “talking” about their issues with trusted friends.  And then I give them the pill they want (sometimes). This has been my compromise:  I tell myself that whatever I can do to keep them out of the psychiatrist’s office (or ER) will be worth it, because once they start down that road, it seems to be an endless downward spiral of medications and side effects. This has been my approach, borne out of my own experience.

Generally speaking, my patients respond well to this approach, and I’d like to believe that they fare better, in the long run, with this approach than they would at many other primary care offices, and much better than most psychiatric offices.  (Of course, my sampling of patients skews towards the “walking wounded” side, patients who fit into the expanded criteria for depression, anxiety, or bipolar illness, who mostly have been conditioned by societal norms and medical authority to believe that they are suffering from a biochemical disease state that requires a chronic pharmaceutical fix.  The dissatisfied patients, those who don’t get what they are seeking from me, probably just shop around for another doctor who will meet their prescription expectations, and thus my sampling may reflect a self-selection bias of those who are receptive to this paradigm shift.)

After finishing your book, I’m not certain that I can continue to justify this tepid approach.  Your book gives a persuasive, evidenced-based, devastating deconstruction of psychiatry’s house of cards, and presents this simple, self-evident truth:  chronic psychotropic medications are not only ineffective, they are also hazardous to mental and physical health, and harmful to society.

I’m not sure how my practice style will change when I head back to my clinic tomorrow, but I can tell you that I have several dozen patients who came to mind while reading your book, patients whose battle with mental illness is paralleling the patient vignettes in your book, and if I ask myself the question, “What can I do to best help this patient now and in the long run?”, then my inclination will be to recommend your book and tell them to exercise, seek healthy relationships, work with trusted counselors, and to be patient, rather than to pull out my prescription pad.  After all, at some point not too long ago, I took an oath to Do No Harm, and even if I can’t help them with their mood disturbance right now, I can at least refrain from offering them a potentially hazardous short-term fix.

I always like to get a counterbalancing viewpoint to these types of issues, so I would be interested to see a reasonable psychiatrist address the numerous concrete concerns your book raises.  Certainly, there are no easy answers to solving this “epidemic” of mental illness, iatrogenic though it may be.  Do you have any further suggestions or resources for practitioners like myself who are looking to break out of this current paradigm of mental health care?

***

Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

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Mark Foster, DO
Letters from the Front Lines: A family physician, after having read Anatomy of an Epidemic, writes of his struggles to prescribe psychiatric medications in a thoughtful way . . . and help some patients wean from the medications.

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