Global leaders in the critical psychiatry movement met on 18 Sep 2015 for a one-day conference to address an urgent public health issue: the iatrogenic harm caused by the over-prescription of psychiatric medications. The event was recorded and can be viewed on this blog, or on the Council for Evidence-Based Psychiatry’s YouTube channel.
We are also editing the talks into shorter videos and these will be made available in the next few days. The speakers’ slides from the event can also be downloaded here.
The conference took place at the University of Roehampton, just outside central London. I was there. It was packed and energetic. Main speakers included Robert Whitaker, Peter Gøtszche, James Davies, Peter Breggin and John Abraham. We were treated to an expert review of the ways in which the widespread use of harmful and barely (if at all) helpful medicines has become the mainstay of psychiatry’s contribution to society.
MiA readers wanting to know more about the Council for Evidence Based Psychiatry can find their way to the website through these links, watch a recording of the conference or download the slides. The conclusions are compelling and they were warmly received by an enthusiastic audience. Were medicines of such dubious value and so obvious a set of adverse effects being used in any other field, their use would be much more tightly regulated, but as we all know that is not how it is. Why is that?
At gatherings such as this, when people discover I am a psychiatrist I often become a lightening rod for their anger and frustration, and I imagine others in a similar situation have had the same experience. It’s okay; it comes with the job, but a couple of things happened at Roehampton on September 18th which reminded me why this can happen, and why all of this is so much more complicated than the simple black-and-white “Pharma and psychiatry bad, everyone else good.”
The first was what happened when one of the audience interrupted a speaker and clearly had more on their mind than the programme could accommodate at that time. The interruption wasn’t welcomed and indeed a threat of forcible removal was made. That didn’t happen and the situation was calmed but there were a few heated moments. The second was a comment from the floor about the adverse effects of antidepressant and antipsychotic medication. The person in question recounted considerable, predictable and prolonged difficulties with adverse effects, dependency and difficulties with withdrawal. When asked “How did you come to be started on them in the first place?” the answer was of course, “The doctor prescribed them.” When asked “Why did you go to the doctor?” the answer was “I was having difficulty sleeping in the course of a some difficult personal circumstances.”
Working as a psychiatrist exposes me to people who want medication as much as it does to those who don’t. We can question why and how those who want medication have come to that position, but it is commonly difficult to shift and the result is frequently a prescription with the advice “OK. If you want to find out whether meds can help, try this and see how you get on.” Hardly expert knowledge or advice, but when it happens, most usually it is a response to a situation that would otherwise result in a request for another opinion and another doctor providing the prescription instead. Many of the distressing stories we heard at Roehampton were of people who had tried one antidepressant after another in the hope of relief … where was the belief that somehow, somewhere there is a pill that can safely and reliably relieve their distress coming from? What was the person who went to the doctor because they were distressed by difficult circumstances actually looking for? They were having difficulty sleeping. The doctor might have prescribed a benzodiazepine sleeping pill, but we are all quite rightly very wary of benzodiazepines, and an SSRI is the more commonly used alternative. This is not because there is confidence it will work, but because that is all the doctor can do under such circumstances, and a prescription is frequently received as a symbolic token of concern and acknowledgment of the recipient’s difficulties.
As a result it often brings-short term relief, and then the cycle repeats. I am sure practitioners reading this will recognise the cycle and the deeper and deeper holes they and their clientele can get into as it goes round and round, but what starts it? Why did that person go to the doctor when they were distressed by difficult circumstances? What were they actually looking for? Could it have been found somewhere else, and if so where? How can our institutions mark and respond to the fact that someone might have become overwhelmed and incapacitated by life’s challenges without having to identify them as “ill”?
It is not just pressure to prescribe from patients or clients that psychiatrists have to field. We are all familiar with situations in which a very distressed, disturbed or confused person is a source of concern to others. As I have mentioned on these pages before I am sure I have signed more papers authorising the detention of someone because others wanted me to, than I have because I’ve been firmly convinced that would be the right thing to do … and if I don’t respect others’ legitimate concerns I am at risk of professional censure. There are critical psychiatrists out there who have been disciplined for not detaining people when others think that should have happened, and of course detaining someone almost always also means medicating them. Put very bluntly, a lot of psychiatric prescriptions are issued (not only to detained patients) because a negotiation has been conducted between the prescriber, the patient and the patient’s associates resulting in “agreement” that the patient should take something to quieten them down. The dynamics of such negotiations are fascinating and often very compelling expressions of social control.
The gathering at Roehampton on September 18th was nothing if it wasn’t one of people keen to see a different way of responding to personal distress and confusion than the current, widespread use of harmful mind-numbing medicines. As a result it was fascinating to see how difficult even a gathering such as that found an episode of social disruption. All credit to the organisers and the frustrated person at the heart of it for settling things down, but there were tense moments which have to remind us how powerful expectations of accepted social order can be. It isn’t nice, but very often psychiatrists find themselves powerless conduits of such forces, and understanding what they do and why has to include a recognition of this. We have been drugging and incarcerating inconvenient people for centuries and although this must change, wider expectations remain and they are deeply embedded in our understanding of how an ordered society should conduct itself. Of course we have to shout as loudly as we can in criticism of those who cynically exploit the opportunities this provides, but we also have to address the core issues themselves.
Doctors, per se do not have a monopoly on a remedy for understandable personal distress, and expecting them to provide it gets no one anywhere. Wider recognition of this might stimulate the development of alternatives.
There is a limit to how much variation an ordered society can accommodate … those limits could and quite possibly should be much wider, but infinitely wide would be unrealistic and unworkable. Relationship, cooperation and collaboration depend upon a degree of mutual conformity. Not everyone can conform all the time. Drugging and incarceration aren’t ideal solutions. Humane and relational approaches have to be more widely developed but the need for some way of responding effectively when one person’s difficulties disturbs the many is unlikely to go away. Obviously there are those who think that what they do is appropriate and justified, but I would venture that many psychiatrists actually do what they do more often because they feel themselves to be powerless servants of wider social pressures, and would dearly like to be able to do it differently.
