Psychiatric Medications Harmful?

I recently got a question from a colleague in internal medicine about Robert Whitaker, of whom I’ve not heard for some reason. Apparently he’s a prize-winning journalist whose opinion about the treatment of psychiatric illness with medications seem to reflect those of many who might be called psychiatry haters.

I shared the link in the following tweet with some of my colleagues in psychiatry, who didn’t really comment.

Choose whichever one you prefer. The recorded interview is probably more interesting than the written story. Notice that I’ve asked readers to compare the Whitaker story with the Psychiatric Times article written by Dr. E. Fuller Torrey, MD:

I think Whitaker’s anecdote (in the recorded interview) about the debate with psychiatrists, one of whom cried that he was sick to death of hearing about evidence-based medicine, was especially interesting.

I shared this with some residents and medical students. One of the medical students seemed to share my opinion that, although much of what he says is provocative, he really doesn’t deliver a blanket condemnation of all psychiatric medications. Like any good debater, he knows how to concede a point. And a quick search of PubMed did turn up a short letter to the editor about antidepressant-induced tardive dysphoria, citing literature which tends to support Whitaker’s premise [1].

I think it’s interesting to compare Whitaker’s criticism of comparing taking antipsychotic drugs long-term to treating diabetes mellitus with Torrey’s remark in the same vein:

“Antipsychotic medications improve the quality of life for most, but not all, patients with chronic schizophrenia, and most of them will require medications for many years—even for life. Thus, in Surviving Schizophrenia, I wrote that for many patients with chronic schizophrenia, “I advise them to continue taking the antipsychotic drugs for the rest of their lives, just as many diabetics have to take insulin for the rest of their lives.” – See more at: http://www.psychiatrictimes.com/psychopharmacology/better-without-antipsychotic-drugs#sthash.IwX13HYc.dpuf

I also thought it was ironic that the author of the paper on antidepressant-induced tardive dysphoria seems connected to many pharmaceutical companies.

I found myself wondering whether mainstream psychiatrists really are all that insecure about medication treatment. I can tell you that even in my residency, the serotonin and chemical imbalance metaphor was being downplayed, so I don’t disagree with Whitaker on that point.

However, I’m less sure about his generalizing his premise about antidepressants to antipsychotics. And it sounds like Torrey would disagree as well,

“According to the NIMH, there are approximately 2.6 million adults with active schizophrenia in the US, which means that approximately 1.3 million are not being treated. The results of this grand, unplanned experiment to ascertain the outcome of untreated schizophrenia are now available in homeless shelters, on the streets, in public libraries and bus stations, and in the jails and prisons where many of these untreated individuals have ended up. The experiment, to say the least, has not been a success.

There is general agreement that some individuals with schizophrenia are better off without antipsychotic drugs. But, there should also be general agreement that many other individuals with schizophrenia are better off taking antipsychotic drugs long-term. As Dr Darold Treffert put it:

It is not “freedom” to be wandering the streets, severely mentally ill, deteriorating and getting warmth from a steam grate or food from a garbage can; that’s abandonment. And it is not “liberty” to be in a padded jail cell instead of a hospital, hallucinating and delusional, without treatment because that is all the law will allow.”

– See more at: http://www.psychiatrictimes.com/psychopharmacology/better-without-antipsychotic-drugs#sthash.IwX13HYc.dpuf

I don’t agree with everything Whitaker says. I suspect his ideas probably are threatening to the professional identities of some psychiatrists.

I also thought this was a golden opportunity to engage my residents and medical students in a discussion about how psychiatrists think and behave as we struggle to find the safest, most humane, and most effective ways to help our patients heal.

In the end, Whitaker raises important questions for us. While I wouldn’t endorse his premise uncritically because I think it can be viewed as a polarizing argument which tends to divide us, his perspective reminds me to be humble.

Polarizing arguments are not what we as a profession need now and our patients deserve better. We need more research and we need to recognize how important it is for doctors and patients to communicate clearly with each other.

By the way, most thoughtful psychiatrists don’t classify every psychiatric disorder in the disease perspective. Most of us are at least aware of The Perspectives of Psychiatry by McHugh and Slavney as well as the practical guide based on that book, Systematic Psychiatric Evaluation: A Step-by-Step Guide to Applying The Perspectives of Psychiatry, by Chisolm and Lyketsos. We apply dimensional, behavioral, and life-story perspectives as well [2].

And most of us do not perceive ourselves as abandoning the Hippocratic Oath.

 

 Reference:

1. El-Mallakh, R. S., Y. Gao, et al. (2011). “Antidepressant-Induced Tardive Dysphoria.” Psychother Psychosom 80(1): 57-59.

2. McHugh PR, Slavney PR. The perspectives of psychiatry: Johns Hopkins University Press Baltimore, MD; 1998. Author’s note: there’s also a new book in this vein, Beyond the DSM: The Perspectives of Psychiatry Approach to Patients

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