One of the first duties of the physician is to
Educate the masses not to take medicine.
– Sir William Osler
Peter Gøtzsche’s new book, Deadly Psychiatry and Organized Denial brings up an important and complex issue. How do psychiatrists get up in the morning and damage people all day long while pretending to help them? The book is elegantly referenced – and I encourage everyone who practices thoughtful psychiatry to read it, because you need to be much better educated to practice high-quality mental health than you do to act as a dispensing machine. Gøtzsche is absolutely right; on all levels psychiatrists are in denial about the damage that they are doing to patients.
The area of denial most interesting to me is at the level of the practitioner. This is where the rubber meets the road. It is one thing to be high in the academic tower, selling misinformation. It is a totally another thing to be its excretory organ. The statistical analyses showing lack of effectiveness and numerous adverse effects noted in Deadly Psychiatry are not just abstractions; this is obvious to the casual observer, and should be painfully obvious to the psychiatrist.
Even taking cognitive dissonance into consideration, psychiatrists can surely see what is in front of their eyes. I remember years ago when Risperdal – the new miracle antipsychotic came on the market. The first patient I gave it to gained about 60 pounds in just six weeks. I have never seen anything like it before. It was hard to believe that this was the same person. He was a man in his early 20’s. His mother showed up with him at the visit, in tears over how he looked.
I have never prescribed Ritalin or other stimulants for children, but have been asked to give second opinions, particularly in cases in which parents are divorced and one parent wants the medicine and another does not. How can a doctor fail to notice stunted growth that makes a 12-year-old look like a 9-year-old? How can a doctor fail to notice all the tics and twitches?
Early in my career I treated a successful song writer who developed florid mania. Of course, I started him on lithium. He also put on a lot of weight, was mentally slow and he couldn’t write songs anymore. Hard to miss that this guy was a shell of his former self.
Patients complained all the time about sexual dysfunction continuing long after stopping SSRIs. Pharmacists know about this problem. Patients are well aware of this problem.
I recall an attorney who was having mild depression related to financial difficulties. He was given samples of Paxil for a month or two, until I ran out of samples. He was unable to afford the prescription. Three days later he attempted suicide.
One patient of mine in therapy for panic attacks with no depression was convinced by her daughter to get an SSRI from her family doctor. She hung herself from a stairway in her house a few days later.
This is not to say that the medications have no place at all in mental health care, but other psychiatrists have to be looking at the same frequent adverse consequences.
There are limits to cognitive dissonance. There are limits to self-deception. While there are times that medications appear to be very helpful, it is impossible to ignore how often they are damaging. Kirsch’s analogy of the emperor’s new drugs is apt, but doesn’t go far enough. I think the emperor knows he has no clothes on, but is scared to admit it. I think that psychiatrists in private practice lead lives of quiet desperation, torn between what they see and what they do.
I think that the situation is more like the famous Milgram experiments. The Milgram experiment on obedience to authority figures was a series of social psychology experiments conducted by Yale University psychologist Stanley Milgram. They measured the willingness of study participants — mostly young male students from Yale — to obey an authority figure who has instructed them to perform acts conflicting with their personal conscience. The experiment found that a very high proportion of people were prepared to obey — albeit while experiencing emotional distress — even if they thought (mistakenly) that they were causing serious injury and distress to another person.
The authority figures in this case are the bought-off academics, their teachings compounded by the nature of medical school and residency training. When entering medical school, and later starting training, the amount of information to be mastered seems massive. Early on, when the damage is new and most noticeable, it is difficult for a student or trainee to point out the problems with damaging treatments. There is a sense that one needs to study more and gather more information before becoming critical. How can a lowly resident question the work of the next-to-God professors (as Biederman described himself, under oath)? Of course, 7 or 8 years later, the young doctor is so embedded in the system that questioning it is likely seen as a form of professional and financial suicide. So, despite personal conscience, psychiatrists continue to drug people ever-deeper into illness. They are following orders. This is Gøtzsche’s organized denial.
Perhaps the twisted experience of causing visible harm just because you are told to do it explains why so many psychopharmacologists appear eccentric. When I see patients for second opinions about what is usually an unnecessary cocktail of drugs for a diagnosis of bipolar disorder, despite the fact that the patient never had a manic or hypomanic episode, I often ask a Socratic question. I ask them to visualize their psychopharmacologist, and ask themselves whether they would buy a used car from this person. Most patients laugh – and say that they would not. So why trust your life to this person?
William Osler, who founded the residency training program, wrote in the 1800’s that the first duty of the physician is to educate the masses not to take medicine. If I were in charge of the APA this would be my primary directive. I would instruct the members not to use any psychiatric drug for which the original, raw data was unavailable, including unpublished studies, for association review. I would not let the companies pay for the review. The pharmaceutical companies can have their “proprietary” information, but the doctors would not prescribe the drugs to patients without knowing the absolute value of the medications. This would benefit patients and doctors alike.