Wednesday, August 21, 2019

Comments by Steven Moffic, MD

Showing 14 of 14 comments.

  • Thanks, Ken.

    If more of the comments were with your kindness, maybe we’d get somewhere. I’m left wondering, too, what the site is for? Thinking about improvements? No! Bashing psychiatry and psychiatrists, yes! But anger goes only so far. Try forgiveness sometimes; it’s healthier and leads onward.

    And, I’ll say it again, Duane and whoever else is recommending how to withdraw from medications is just about practicing medicine, but without the license. As much as commenters scour the literature on medication, some follow-up is needed to be published about what happens to these people who take that advice. Who knows? Maybe psychiatrists will learn something.

  • Yes, agree with you completely about the institutional racism, having specialized in cultural psychiatry my whole career. Institutional preferences filters down to clinicians, and of course most clinicians have their own conscious and unconscious biases. Whatever may be wrong with mainstream mental healthcare is ever more so when minority groups are isolated. For Black-American males, in a blog for a different site (www.behavioral.net), I’ve called they being rounded up into prisons “Aparttime”.

  • Of course, the discrimination in our mental health systems go beyond Black-Americans to Hispanic-Americans, etc. and most especially, but most ignored, Native Americans. These are not all “people of color”, a very misleading term since we all have skin color. The key here is darker skin color.

    Note the absence of such ethnic groups from the list of bloggers here. Yes, we have much work to do. Members of all these groups generally get more medication than psychotherapy, and we know the risks of that.

  • Sinead,

    From one grandfather to one grandmother, I, too, do not want to leave any messes for my grandchildren. That was why I became an activist in addressing climate instability, among other causes.

    I really think you are generalizing way too much about psychiatrists. As others have told me loud and clear, it may be hard for psychiatrists to appreciate the pain they cause (inadvertantly or not) patients and their families. Likewise, if you are not a psychiatrist trying to understand the complexity of a person in pain, you may not realize how hard it is to distinguish and recognize side effects versus emotions. Take akathesia, that horrible, horrible restlessness. At milder degrees, it can look like, and feel like, anxiety. It is probably what led to the suicides involved with the SSRIs. I have a horrible image that often replays in my mind of a patient running down the hall in the hospital and running right through a glass door; this was during my training and we finally figured out it was akathesia from Prolixin. The makers of Prozac may have known about this but not conveyed the risk; no excuse for psychiatrists, but very hard to recognize. And, not being humanistic? Well, that’s what other physicians say we are too much – bleeding hearts afraid of blood.

    Some may be interested in a new blog I did for Behavioral Healthcare, http://www.behavioral.net on Independence Day for Patients, if only to blast it. Another one of my retirement deliberations is at Psychiatric Times. I’m sure there is a lot there to criticize too.

  • It’s getting harder and harder for me to follow these comments as they seem out of order to me. Regardless, I particularly want to thank Altostrata for understanding that I have been trying to apologize and that condemning Cymbalta was indeed a peace offering of sorts. Then, Nathan seemed to second that.

    I also appreciate that this has led to some discussion about Wellbutrin. No, we don’t routinely check blood pressure as that has not been deemed a common side effect at all, but maybe we should. Perhaps that risk was another one hidden by Pharma. After all, Wellbutrin has characteristics in common with the stimulants and we need to check blood pressure regularly with them.

    And, Duane, you got your wish. I have saved enough (though not mainly through work – psychiatry is not a particularly lucrative unless you do a procedure like ECT), so I am retiring from clinical work in a week. Another one bites the dust! Yeah! Maybe a retirement column to follow.

  • Sinead,

    Please do let us know what you find out about Wellbutrin. It is very curious that it was left out of Mr. Whitaker’s book. I long had recommended it be the first antidepressant tried because at therapeutic dosages it had limited side effect problems (nothing sexual)and seemed not to have withdrawal symptoms of consequence (though maybe Duane knows more on that). It is risky for seizures at over 450mg for some period of time.

    I agree with you about the limitations of this sort of communication. Unfortunately, it makes it easy to hide behind some sort of anonymity.

  • Duane,

    Let’s be clear here. Of course, I take responsibility for my patients from whatever recommendations I end up doing. You and others may say you are not practicing medicine when you list withdrawal recommendations, but it sounds like medical practice to me. You may recommend “clinical support”, but how often is that obtained? For those psychiatrists that you feel have done wrong, have you reported them to the state licensing boards?

    The reason I don’t post all my blogs here is that I think different audiences are receptive to different ideas. It is obvious that I am posting less and less here because there doesn’t seem to be any useful dialogue. It seems to me the goal of welcoming people with different points of view is not being honored at all here.

    The Whitaker blog is only an excerpt. Why not post the whole thing. And, I would love for Mr. Whitaker to comment on it.

  • Steve, I believe your comment is so important, to try separate the profession of psychiatry from all psychiatrists. Much of the direction the field has taken were led by so-called “thought leaders” and everyday psychiatrists were hopeful that the biological model would help people quicker than psychotherapy. They really were well-meaning.

    For me, maybe what was noticed in these and other excerpted blogs were taken out of context. I’ve never been a biologically-oriented psychiatrist, though many here want to paint me as one. I’ve decried this model and tried to re-establish the need for a bio-psycho-social-spiritual one. I was a past President of the American Association for Social Psychiatry.

    As to Cymbalta, I belatedly did prescribe it, with the best knowledge I had. I’m afraid some of the information commenters here do not get to mainstream psychiatrists because of the vitriol. Even so, all is not so simple, even with Cymbalta. For depression, there are certainly, again, patients who swear by its short-term help. Side effect problems seem pretty rare to me. And, given the similar tragedy we have with the overprescribing of the dangerous opiates, if Cymbalta offers some pain relief to some patients, by all means. Yes, it is hard to discontinue, though most physicians don’t know there is a lowest dose of 20mg.

    Finally, since I anticipate someone will excerpt something (as has been done before to make an out-of-context point) from a recent blog I did for Psychiatric Times on Mr. Whitaker’s book, it is there and the article was geared to improving both the profession and the work of individual psychiatrists.

  • Stephany,

    Much thanks for your reply, and I, too am beginning to lose hope that we will ever be able to work together, that is, most psychiatrics and our critics. No, I don’t know Duane’s, whole story, but I tried to communicate with him personally as best as I could, person to person off this blog. However, that ended unilaterally and all I’ve gotten back is some vitriolic attacks on me and my knowledge base. I don’t think we will listen well to such attacks, which is why so few psychiatrists participate on this site.

    I posted this Cymbalta blog to try to add to the collective wisdom and knowledge here. I hoped I would not be attacked again, but expected I would. Certainly, I and many psychiatrists have known about the risks of the antidepressants over the years, though we are often bombarded with contradictory information. We try to treat each patient as an individual, and should provide as much informed consent as possible. We do this using our training, experience, and ethical oath. I do know there is a lot of poor treatment out there. As a medical director of a not-for-profit managed care system, I refused to authorize payment for such poor treatment planning (again, see my book The Ethical Way).

    However, when Duane or anyone gives medical advice to people about how to come off medications, they are acting like physicians. As such, they should do studies just like we do. Someday, if not already, such advice will backfire and there may be lawsuits. Although Cymbalta and the like can contribute to suicide, I think via the side effect of akathesia, as a clinician I’ve seen many more patients with high suicide become better with short-term usage and careful monitoring. I hope that those who make withdrawal recommendations are as careful. Who knows, if we really could work together, maybe we could do some comparative studies together.

    Lastly, and perhaps most controversially, it seems like those who have been hurt and traumatized in their interactions with psychiatrists, they displace their natural anger on all psychiatrists. We are like a trigger to the pain. But we are not all the same.