Dr Niall McLaren May 22, 2018
“We have now sunk to a depth where the restatement of the obvious is the first duty of intelligent people” (George Orwell: Review of Bertrand Russell, in The Adelphi, January 1939).
If we learn one thing from the Royal Commissions into child sexual abuse and the banking and insurance industries (see note 1), it will be this: left to themselves, secure institutions will never conduct the sort of self-critical analysis that the larger society expects — and deserves.
In late February this year, a conference on Mental Health in Crisis was held in Sydney and then at five cities in New Zealand. Major speakers included Prof. Peter Gotszche, of the Nordic Cochrane Centre; Bob Whitaker, from Boston; Dr Melissa Raven, from Adelaide; Prof. Roger Mulder, from Dunedin University, NZ; and Maria Bradshaw, from Auckland. I spoke about studies on ECT and several other speakers contributed their harrowing personal experiences of psychiatry.
Subsequently, an article in a New Zealand paper was critical of antidepressants, which provoked the Royal Australian and New Zealand College of Psychiatrists (RANZCP) to issue a press release (March 9th 2018; taken down soon after) which was openly hostile to the idea that people could criticise antidepressants. As part of that press release, it was claimed that psychiatrists “only ever (prescribe drugs) in partnership with the patient and after due consideration of the risks and benefits.”
My experience is that this claim is absolute rubbish and I lodged a complaint with the RANZCP to this effect.1 On April 27th, I received a letter from the president of RANZCP, Dr Kym Jenkins, assuring me I had it all wrong, the RANZCP meant no harm, but she firmly reiterated the claim that provoked my complaint:
“I wish to highlight the College statement goes on to say, ‘the prescription of…medications is something that a psychiatrist only ever does in partnership with the patient and after due consideration of the risks and benefits.'”
As a result, I thought I should check the veracity of her claim. After a quick survey of my practice, I submitted a paper to the lesser of the two RANZCP journals, Australasian Psychiatry, on May 6th. The following is a slightly amended version:
PROVIDING INFORMATION ON PSYCHIATRIC DRUGS: A PILOT STUDY
Following adverse reports in a New Zealand newspaper regarding the efficacy and safety of psychiatric drugs, on March 9th 2018, the Royal Australian and New Zealand College of Psychiatrists (RANZCP) issued a press release in rebuttal: “Claims by New Zealand newspaper The Press that antidepressant and antipsychotic medications don’t work are highly irresponsible and potentially very stigmatising for people experiencing mental illness…”
It continued: “Psychiatrists are highly trained medical professionals with expertise in managing both physical and mental health…. The prescription of antidepressant or antipsychotic medications is something that a psychiatrist only ever does in partnership with the patient and after due consideration of the risks and benefits.”
It has long been my experience that patients report they were given little or no information relating to the major side effects of psychotropic drugs, in particular, the risks of obesity, sexual dysfunction, akathisia, aggressive and suicidal impulses, neuroleptic malignant syndrome, and dependency. In view of the sweeping claim quoted above, a preliminary file survey of my current patients was undertaken.
Mine is a private, bulk-billing (government-funded) practice in working-class areas of suburban Brisbane. Compared with standard private practices, patients are typically younger, more likely to be male, immigrant, unemployed or on disability pensions, and with histories of major family disturbance, poor schooling, poor work records, social disruption, crime, and drug and alcohol abuse. That is, they are typical of out-patients in any public service in most countries.
Of 176 current files, nearly half the patients had a history of prior psychiatric contact. Their files were checked to see if they had been given information on the nature of the disorder and side effects of the drugs. Where the information was not recorded, patients were asked the following questions, either at their next attendance or by phone or email:
What were you told about how this drug works on your diagnosis?
Were you told about its side effects?
RESULTS
The results are shown in the accompanying tables. Because this is a pilot study with small numbers, results have not been converted to percentages. At the time of referral, 135 of a total of 176 current patients were taking psychotropic drugs (Table 1). In 82 cases, the drugs were prescribed by a psychiatrist while the remaining 53 were prescribed by general practitioners (GPs). There was a clear tendency (not shown in the table) for male patients to have seen psychiatrists while female patients were more likely to have been prescribed drugs by their GPs.
Question 2 could have been refined as there were two parts to it: Were you given a formal diagnosis? and How does this drug work in your condition? Of the 82 psychiatric patients, only 23 stated that they recalled having been given information on the mode of action of the drugs (Table 2). Most people who recalled a diagnosis stated they were told only a name (schizophrenia, bipolar disorder, ADHD etc). There were either told or they assumed it amounted to a “chemical imbalance of the brain.” This, however, misses the point that 59 out of 82 patients (72%) didn’t understand why they were taking their medication. There appeared to be no difference between private psychiatric practices and public services.
The most telling result is for information on side effects (Table 3). No patients with previous psychiatric contact had been given any more than the most superficial information relating to side effects (e.g. “It might make you a bit drowsy” of olanzapine).
To reiterate, these questions were asked:
What were you told about how this drug works on your diagnosis?
Were you told about its side effects?
Typical responses were as follows (expletives deleted):
Mrs JH, a 54yo mother first admitted to hospital at age fifteen, had had something like twenty admissions over the years, with at least twenty-five different drugs as well as fifty ECT. At the time, she had just been discharged and was taking four drugs:
Q1: “They never said anything. In those days, they didn’t even talk to you. Still don’t.”
Q2: “Of course not.”
Mr DT, a 29yo fireman injured in a fall, became intensely agitated after he was prescribed fluoxetine so was referred to a psychiatrist:
Q1: “They just said I’m bipolar and that’s that. Maybe somebody said something about brain chemicals or I read it somewhere, I don’t know. I think it was the antidepressant messing with my brain. I’ll never take them again.”
Q2: “I wasn’t told anything. They put me on lorazepam (7.5mg per day) but nobody told me how addictive it is. It’s a nightmare, that stuff, they shouldn’t be allowed to prescribe it.”
Ms TM, a 26yo social worker, was treated with large doses of antipsychotic and antidepressant drugs after a brief psychotic episode following major stressors. After taking olanzapine 40mg per day and mirtazapine 45mg per day for fifteen months, her weight went from 58kg to 105kg:
Q1: “They kept telling me I’ve got a chemical imbalance of the brain and I’d have to take drugs for life. That was so depressing, I can’t tell you.”
Q2: “No, they never said a thing. I kept telling the doctor I was gaining weight but she just said I should watch my diet. I assumed it was my fault, that made me feel even more guilty.”
Mr KV, a 29yo military veteran discharged after sustaining a major back injury, was prescribed a range of antidepressants as well as quetiapine as a hypnotic:
Q1: “They didn’t say a thing. Nobody said anything.”
Q2: “You’ve got to be joking. Nobody said a thing about side effects, especially about losing your sex life. I’d like to give (quetiapine) to that psychiatrist and see what he thinks of it.”
Ms BM, a 23yo student, developed a psychotic state after she started using marijuana and other drugs, including methamphetamine. She was prescribed perhaps a dozen different psychotropic drugs in rapid succession but her mental state did not settle. She gained a great deal of weight and was constantly confused and erratic. In response to the questions, her mother said:
Q1: “They said she’s schizophrenic but she was the brightest and happiest girl before this. I don’t believe it, there’s no mental disorder in our families, how can it be genetic? They said the drugs would fix her condition but she’s not getting better. Now they’re calling it treatment-resistant schizophrenia.”
Q2: “We were never told a thing. The hospital tell us over and over again the drugs are safe and non-addictive but it’s not true. And the weight she’s gained, she was such a pretty girl, now look at her.”
Mr BW, a 42yo post-graduate, had had about twelve admissions to private hospitals over twenty years. He had had every available drug, often in huge doses:
Q1: “I’ve been given every diagnosis, schizophrenia, bipolar, autism, social anxiety, depression, the lot. What causes it? Oh, something chemical, that’s what they say.”
Q2: “Of course not. I’ve been on everything but there’s no point complaining, they’d just say it’s my disease and I need more drugs. Quetiapine was the worst, it drove me completely mad. I found out it’s called akathisia but the psychiatrists didn’t believe me, they said I’m schizoaffective so they gave me ECT.”
Mr EG, a 49yo senior manager with several admissions to hospital:
Q1: “I’m bipolar, is that what you mean? They say it’s chemical, the drugs will fix it.”
Q2: “Nothing. They don’t believe their drugs have any side effects. I told them I couldn’t think because of the lithium so they stopped it suddenly and of course, I flipped out. They said that’s my disease coming back. It wasn’t, it was drug withdrawal, I’m not stupid.”
Mr GD, a 43yo man, has had a singularly torrid psychiatric history. His father recently said: “They asked whether he’d ever had clozapine. I told them he’d had it twice but each time they had to stop it because it affected his heart. I said they couldn’t give it but they went ahead anyway. He refused so they held him down and squirted it down his throat. Then his enzymes went everywhere and the cardiologist told them to stop it.”
DISCUSSION
On these results, the claim that psychiatrists “only ever” prescribe drugs after discussion of the risks lacks empirical justification. It would be more appropriate to characterise it as “hardly ever.” The question arises: How could a responsible professional body make an assertion which appears to be so patently wrong? The philosopher, Harry Frankfurt, has written extensively on the concept of truth and falsity.2 He defined a lie as “…an act with a sharp focus. It is designed to insert a particular falsehood at a specific point in a set or system of beliefs, in order to avoid the consequences of having that point occupied by the truth. This requires a degree of craftsmanship…” The liar, he said, knows precisely what he is doing. He knows the truth and wishes to lead his audience away from it.
However, between truth and falsehood, there is another epistemological category, in which the speaker’s utterances are neither true nor false but are designed to sway the audience to a particular conclusion regardless of the facts. This Frankfurt called ‘bullshit,’ which is “…more expansive and independent, with more spacious opportunities for improvisation, color, and imaginative play. This is less a matter of craft than of art.” The ‘bullshit artist’ is recklessly disregarding of the necessity for truth; it is a tool to be wielded but not a value in itself. Certain fields of discourse, such as politics, advertising, sport, entertainment, fashion, etc., lend themselves to bullshit. It is unfortunately also true of psychiatry.3
We can now attempt to categorise the statement in the College’s press release. Was it just a matter of the College officials cobbling together a statement to calm the jittery public so they keep taking their tablets, i.e. did it meet criteria for bullshit? It seems unlikely because, as this survey shows, it was a statement that could be falsified with the greatest of ease. In general, bullshit statements are not of this form but are largely matters of taste or sentiment: “This great country of ours…” “Our wonderful sports heroes..” Others relate to the future: “We will bring jobs and growth.” “Make our country great again,” etc. Crucially, because they are neither true nor false, most bullshit statements cannot easily be refuted.
Moving to the category of frank lies, it is an essential part of the definition that the speaker is fully cognisant of the truth but carefully and deliberately changes something critical to mislead the audience. Does that apply to the college’s action in issuing this press release? This is problematical. If, for example, the public became aware of the true risks of obesity, diabetes, sexual dysfunction, suicide, etc, what would happen to psychiatry’s reputation? I believe a reasonable person could conclude that the statement was factually false but was no more than a panicky attempt to retain control of the narrative that psychotropic drugs are safe, effective and are only prescribed for noble reasons. That is, they can use the defence coined by the eminent immunologist, Peter Medawar4, in his review of Teilhard de Chardin’s book, The Phenomenon of Man:
“(The) author can be excused of dishonesty only on the grounds that, before deceiving others, he has taken great pains to deceive himself.”
CONCLUSION
It appears that, at least, the RANZCP has left itself open to the charge of self-deception. That is, while the authors of the press release probably believed what they were saying, they were recklessly deficient in ensuring its truth. Either way, it is a matter of the utmost gravity that this question should ever arise, especially as it is not the first time.5 We owe it to the general public, to our paymasters and to our patients to ensure that everything we say about drugs and treatment is true, not just a self-serving, highly selective reading of the evidence. Regardless of how embarrassing it may be, a thorough and open examination of these two matters is long overdue, i.e. the question of whether psychiatric drugs are all they are touted to be, and how it could be that a major professional body could be misled. If we do nothing, then the profession of psychiatry itself will be in grave danger. Overwhelmingly, this is a message psychiatrists don’t want to hear.
*****
On May 12th, I received the following letter of rejection from the editor of the journal Australasian Psychiatry:
11-May-2018
Dear Dr McLaren,
We thank you for your submission to the journal and regret that we cannot publish your paper on this occasion. Although this is a worthy topic of investigation, there is no methods section within your paper and it is assumed that you have reviewed the files of a single clinic. The results are influenced by subjectivity and recall bias.
Yours sincerely,
Dr Vlasios Brakoulias
Editor, Australasian Psychiatry
In an interview on their long-term study on antidepressants by Hengartner et al, the lead author said:
“…due to institutional corruption within academic psychiatry, it is quite difficult to successfully pass the review process with such papers. Most psychiatric experts reviewing for the leading scientific journals refuse peremptorily any report calling into question the merits of psychiatric drugs.”
I have previously published a critique of the psychiatric publishing industry that essentially concludes it is seriously corrupt.6 I submit that what we are seeing in this small case is a typical example of the almost-unconscious self-deceit that now characterises mainstream psychiatry. In the first place, the claim of the president of RANZCP, Dr Kym Jenkins, that psychiatrists “only ever” prescribe drugs after due discussion of pros and cons is not just empirically false, but laughably so. I will accept that, in rushing to complete the press release, it may have been the case that its author(s) took liberties with the claim, but when she restated her claim in her response to my complaint, she had my survey to hand. In the face of such evidence, it is impossible to claim that psychiatrists always do their duty by the patient and tell them about the side effects: here were dozens of cases, taken at random over the past six months, in one small practice, which categorically contradict her statement. I submit that any reasonably educated and fair-minded person could conclude that the president of the RANZCP, Dr Kym Jenkins, was at the very least recklessly deficient in her view of psychiatrists prescribing potent psychoactive substances.
Turning to the rejection advice issued over the name of a well-known academic, I agree my survey wasn’t perfect, that’s why it was subtitled “A Pilot Study,” but I will state flatly that I hope he didn’t expect me to believe his reasons because I don’t:
“One has to belong to the intelligentsia to believe things like that: no ordinary man could be such a fool” (George Orwell, Notes on Nationalism, 1945).
I find his excuses totally disingenuous and meretricious. I am absolutely certain that if any of his academic friends or their acolytes had submitted a paper which lacked a methods section (actually, that’s not true: it was clearly described in the paper), then they would have received a friendly email pointing out their error and inviting them to correct it. However, it’s the bit about “subjectivity and recall bias” that grabs attention.
When I trained, admittedly a very long time ago, psychiatry was actually about subjectivity. That’s what mental life is, so I think it is entirely fair for patients to respond “subjectively” to how they are managed. I have another patient whose weight went (objectively) from 50kg to 103kg (106% gain), entirely by the well-known, objective effects of mirtazapine and quetiapine. Subjectively, she was severely pissed off and I believe she had a right to be. Objectively, it cost her a lot of money for new clothes; subjectively, it filled her with horror and her fragile self-esteem finally shuddered and expired. Objectively, when the drugs were stopped, she lost most of the weight but subjectively, she loathed the stretch marks it had given her. So when Dr Vlasios Brakoulias, senior lecturer in psychiatry at the Nepean Clinical School of Sydney University, says a perfectly objective paper, i.e. counting responses from patients, is too “subjective” for his journal, I dismiss his objection as just another example of what Hengartner called “institutional corruption within academic psychiatry.” It actually meets the definition of bullshit, given above, but the matter is far too serious for that label.
Turning to the question of “recall bias,” I will concede that, yes, human memory is a bit of a problem (especially at my age) but I do not doubt that the patients said what they believed to be true. If they said they were told nothing, then that is what they believed. If, as a matter of historical fact, they were told something else, that is, for the purposes of psychiatrists managing the mentally-disordered, just a signal that they need to lift their game. All that counts is that the patients have no recollection of being given adequate information on the side effects of their drugs. In any event, I submit that in this type of study, any recall bias will be self-correcting, meaning patients are just as likely to believe that something they read or heard somewhere must have come from the psychiatrist as they are to have forgotten what was said to them. The case of Mr TD confirms this.
Also not included in the quotes was a 46yo woman who developed very obvious and distressing tardive dyskinesia of the face and arms as a result of eight years of quetiapine (which she shouldn’t have been prescribed, but that’s another story). Was she warned about this terrible side effect? When I rechecked with her this week, she again said she wasn’t. From years of experience, I don’t have enough confidence in the quality of the case notes of the Queensland Mental Health Services to go back eight years and see if it was recorded that yes, she was given full product information on this drug. You can believe this: she wasn’t. So much for “recall bias.” It is one of those slippery labels that can be used to justify “inherent bias,” aka self-serving prejudice.
So where does this leave us? Are we going to trust what patients tell us or do we dismiss it as biased and subjective, self-serving whimpering? For myself, if I have to choose between trusting the honesty of my patients, or trusting the honesty of mainstream psychiatry, it’s a no-brainer. And my recent correspondence with two of the most senior officials of the Royal Australian and New Zealand College of Psychiatrists confirms to me that I have made the right choice.
Note 1: A Royal Commission is the highest level of enquiry in Australia, similar in powers and scope to the Mueller commission in the US. Each Commission is established by an Act of Parliament and has very extensive powers of investigation and subpoena, as well as punitive powers. The current Liberal government fought for years to block the Royal Commission into the banking and insurance industries; now that it is in session, we see why.
Show 6 footnotes
Previous articleCan Precision Medicine Work for Depression?
Next articleThe Impacts of Structural Stigma With Mark L. Hatzenbuehler
Niall McLaren
Jock McLaren is an Australian psychiatrist who worked 25yrs in the remote north of the country. He occupies himself delving into the philosophical basis of psychiatry, only to find there isn't one. This has not helped his popularity with his colleagues, now well into negative territory.
Thank You Dr McLaren and MIA.
No comments:
Post a Comment