Letters from the Front Lines

Dear Bob–

I’ve had a couple of remarkable conversations, not with my own patients, but with friends and acquaintances asking me for advice.  Each example depicts so much that is wrong with the biomedical model of mental health care.

First, a woman contacted me through a mutual friend.  She was placed on Celexa five years ago for reasons she’s not even sure about.  She was depressed after a divorce and not sleeping well, went to see her doctor, was placed on Celexa, was never again asked to stop it, or even reassess if she still needed it.

She gained over fifty pounds on the Celexa and eventually decided that she wanted to come off of it.  Her family doctor strongly advised her against this, but she did it anyway.  Without guidance, she went off cold turkey and had some terrible withdrawal reactions, but she started to lose weight and began feeling better overall after a few weeks, though more emotional. To her, the increased emotionality was not so bad.  In fact, she realized only after being off the Celexa how numb she had felt while on it.

She went back to see her doctor for a different problem.  She was nervous to tell him that she went off the Celexa, because he had been so adamant that she remain on it.  To her embarrassment, the second he walked into the exam room, she began bawling.  He said to her, on the spot, without further questions, “The nurse told me you stopped your antidepressant.  See, you clearly need to be on something.”  She told him through tears that she didn’t feel depressed, but he wasn’t buying it.  “This is not normal,” he told her as she he continued to cry.  He convinced her to try a brand new medication, Viibryd, that he said works great for depression and wouldn’t cause weight gain.  (I’m guessing he’d just been visited by a drug rep recently.)  He gave her three months of free samples.

She started the medication and immediately began having stomach issues.  Her doctor did not tell her that digestive problems are the most common side effects of Viibryd.   (I bet he didn’t even know.)  Instead, he told her she had GERD (esophageal reflux), and started her on a prescription antacid.  When she continued to get worse, he doubled her dose of it.  In spite of the stomach problems, she started gaining weight again, ten pounds in three months.  At this point, she was convinced the problem was with the Viibryd, but she was scared to talk about it with her doctor.  So she talked about it with her friend, who put her in touch with me.

I have not consulted with this woman personally, but from what I gather, it seems absurd to think that she has a pathological emotional problem requiring drug treatment.  It’s clear that she has been harmed physically and mentally by the various drugs she’s been placed on for her non-disease.  And yet, short of a chance connection with me, she never found within the vast health care system a provider who told her it was okay to be emotional, that she didn’t need a pill to make her “normal,” that the physical and emotional ailments she was experiencing were likely because of the drugs.  Also, I find the paternalism that her doctor displayed very disturbing.

Second, I received a phone call from a friend in the midwest.  A year ago, his wife gave birth to their fourth and final child.  She became very depressed during the time she was weaning her infant from breastfeeding.  She called her obstetrician, and over the phone she was told she had post-partum depression and was prescribed an antidepressant, Paxil.  This seemed to help her feel better, dramatically so.  Her husband–my friend who was so worried about his wife’s mental health–didn’t know what to think, but was glad to see her feeling better.  He asked her, “How long will you need to stay on it?”  She didn’t know.  Her obstetrician never told her how long to stay on it, what the side effects were, had never recommended any non-medical treatments like diet or exercise or counseling.  She thought she might need to be on it for life.

This didn’t seem right to my friend.  Why would she need to be on a pill for life just to feel well?  Through social networking, he was aware of my involvement in mental health reform and he asked me a few questions and started doing his own research.  He purchased “Anatomy of an Epidemic” to try an educate himself on these matters.  He became concerned about the long-term consequences of the medications for his wife, especially when, after about six months on the Paxil, he noticed a worsening of her anxiety and depression, as well as some personality changes.  Her doctor, instead of questioning her need for the medication in the first place, instead increased her to the maximum dose of it, again over the phone.

Paternalism.  Reflexive prescribing.  Willful ignorance to side effects.  A paucity of alternatives offered.  I feel so ashamed of my profession at times like these.  I feel like screaming, “Don’t go see your doctor if you’re feeling sad or anxious!  The only thing he or she can do is put you on a pill you don’t need, that may hurt you, that may make your sadness and anxiety worse over time!”

Of course that’s not true.  There are many conscientious, insightful doctors who only use drugs judiciously and as a last resort.  But there are so many that just accept–and promote– the biomedical model, hook, line and sinker.

Who are patients going to see in their hour of distress?  Who else will step up to help them navigate the waters of emotional pain, just when they are most vulnerable?  The system–meaning the drug marketing, the insurance companies, government programs, media coverage, cultural norms–these all funnel wounded patients towards their primary care doctors, whose drug closets are bursting at the seams with samples of the latest and greatest wonder drugs.  It is primary care doctors who prescribe 75% of psychotropic drugs in this country.

And another problem is that a lot of patients just want that pill anyway.  It’s so easy to take a pill, so hard to do things like exercise and eat properly.  Doctors perceive that patients expect pills.  They don’t know what else to offer.  It’s so hard to motivate someone to change their lifestyle.  There’s no real incentive for doctors to investigate or recommend alternatives.  And thus the negative feedback loop accelerates.

This is system failure.  It’s devastating to see patients and friends who only want to feel well, and wind up getting ground up in the gears of the machine.

Mark

Editor’s note: These letters are selected from an exchange that Dr. Foster and Robert Whitaker have had since he read Anatomy of an Epidemic. They describe his interactions with his patients, and his changing thoughts about the prescribing of psychiatric medications. In all of these letters, the specific patient situations he describes are real, but all identifying characteristics have been altered or obscured, or permission has been sought, in order to protect patient privacy.