Dr Pies is Professor Emeritus of Psychiatry and Lecturer on Bioethics and Humanities, SUNY Upstate Medical University; Clinical Professor of Psychiatry, Tufts University School of Medicine; and Editor in Chief Emeritus of Psychiatric Times (2007-2010). Dr Pies is the author of several books. A collection of his works can be found on Amazon.
You have read the blogs and seen the placards a dozen times: doctors prescribe too many “drugs” for too many patients. Psychiatrists, in particular, are popular targets of politically motivated language that seeks to conflate the words “medication” and “drug”-thereby tapping into the public’s understandable fears concerning “drug abuse” and its need to carry out a “War on Drugs.”
You have read the blogs and seen the placards a dozen times: doctors prescribe too many “drugs” for too many patients. Psychiatrists, in particular, are popular targets of politically motivated language that seeks to conflate the words “medication” and “drug”-thereby tapping into the public’s understandable fears concerning “drug abuse” and its need to carry out a “War on Drugs.” Misleading radio ads promise “drug-free” treatment of panic disorder (certainly possible, but not always achievable) and the Internet bristles with the phrase, “psychiatric drugging.” (My Google search pulled up 9310 results.) And, all too predictably, any physician who argues that psychotropic medication is often an effective and lifesaving intervention is hustled off to the perp line of “drug-company shills.”
All this will not surprise students of language, history, and philosophy. Those who control language are well positioned to control thought and behavior. If government officials can persuade the public that killing innocent civilians is merely “collateral damage,” they have gone a long way toward justifying the carpet-bombing of a village. If the forces of antipsychiatry-and they are alive and well-can persuade the public that psychiatry is “drugging” people, they have gone a long way toward marginalizing and discrediting the profession. To understand how powerful the words “drug” and “drugging” are, imagine the feckless campaign that would be waged if the perennial protesters in front of the American Psychiatric Association’s Annual Meeting carried signs that read, “Psychiatrists: Stop Medicating Your Patients!”
Philosophical problems begin when language goes on holiday.
-Ludwig Wittgenstein, Philosophical Investigations
Is this all merely a matter of “semantics” or-in the parlance of postmodernism-“competing narratives”? Is there any scientific reason to distinguish “drugs” from “medications”? And finally, what are our ethical obligations as healers when medication is administered, either voluntarily or involuntarily?
There is, of course, a qualified scientific case to be made against overuse of some psychotropic medications. In the first place, we have far too many medications that employ the same old mechanism of action, with only modest efficacy, and too many unacceptable adverse effects. The so-called atypical antipsychotics (AAPs) are good examples. With the exception of clozapine-and possibly risperidone and olanzapine, according to a meta-analysis-the AAPs are not substantially more effective than the first-generation neuroleptics.1 Meta-analyses, of course, must be viewed cautiously, since the studies that compose them may be flawed or biased, and unpublished “negative” studies may be excluded, as my colleague S. Nassir Ghaemi, MD, has pointed out.2 Thankfully, decreased rates of tardive dyskinesia with the AAPs are a bright spot in this otherwise dour assessment, and this is no trivial gain.
Nonetheless, the metabolic adverse effects of the AAPs (weight gain, lipid and glucose dysregulation, and so on) are substantial problems and call into question the goal of expanding the labeled “nonpsychotic” indications for these medications.3 We sorely need to escape from the “D2–5-HT2–me too” paradigm-antipsychotics that block mainly dopamine-2 and various serotonin receptors-and uncover more fundamental mechanisms of antipsychotic action. Critics of psychiatry are indeed justifiably skeptical regarding “Big Pharma’s” concerted efforts to expand the use of AAPs to the treatment of nonpsychotic conditions, for which effective and better-tolerated medications are already available. And yes-many of these same critics are quite properly alarmed at the decreasing use of psychotherapy in psychiatric practice.4
And yet, psychiatrists must resist those who would hijack language in the service of their narrow political agenda-that of discrediting psychiatry and psychiatric treatment. We must begin by pushing back against the campaign to eliminate psychiatric “drugs,” by pointing out that there are substantial biochemical and clinical differences between many life-enhancing psychotropic medications and drugs of abuse, such as heroin and cocaine. For example, contrary to the notion that antidepressants produce only “cosmetic” changes that “cover up symptoms,” we now have compelling evidence from animal models that antidepressants are working at the deep, structural level of the gene. Thus, antidepressants are known to increase production of various nerve growth factors and to enhance the “connections” between neurons. Indeed, a 2007 review by Schmidt and Duman5 concluded that “hippocampal atrophy is observed in patients with depression, and this effect is blocked or reversed by antidepressant treatments.” A similar case for benign neurotrophic effects can also be made for lithium and possibly some of the atypical antipsychotics.
Let me be clear: as physicians and healers, psychiatrists have an ethical responsibility to see that medications are prescribed and administered in a compassionate and noncoercive way, consistent with the principles of informed consent and respect for personal autonomy. When informed consent from the patient is not possible-in certain emergency situations, or when the patient lacks the cognitive capacity to make informed medication decisions-we must ensure that medication decisions proceed from “due process of law.” This may require obtaining a legal guardianship, or seeking a judicial determination that involuntary medication is justified. And, beyond informed consent, our medication decisions should consider the patient’s personal, cultural, and spiritual needs, as articulated by my colleague, Cynthia M. A. Geppert, MD, PhD.6
Yes, one can argue that in today’s setting of “mis-managed care,” psychotropic medication is sometimes prescribed too readily when psychotherapy would be the preferred treatment. And, yes, we need more effective medications in psychiatry, used in more judicious ways-particularly in children, adolescents, and those with dementia, for whom our evidence-base is often shaky. We should be wary of attempts to expand both our disease categories and the labeled indica-tions for psychotropic medications. But to lump all psychotropic medications in with drugs of abuse is to embrace junk science and junk rhetoric. Psychiatrists need to find a gentle but persuasive language of resistance, in the face of this ploy.
FEEDBACK BY DR GREEN:
I was impressed by your editorial that countered some of the strident and angry accusations of antipsychiatry. However, I fear that you underestimated the responsibility of the profession. Motivational interviewing techniques help us minimize resistance through empathy, validation, curiosity, and flexibility. In this case, psychiatry needs to appreciate that some of the outrage and extremism of the antipsychiatry movement comes from our unwillingness to listen and take responsibility for the harm we have caused and continue to cause. People who feel mistreated form movements because they feel unheard and disempowered.
While you reference how those who control language can influence thought and behavior, you seem to be pointing at those who rail against psychiatry’s abuses. This is ironic, for Foucault and others taught us that the psychiatric profession defines madness, pathologizing and silencing difference, dissent, and the right to make mistakes. Your passionate defense of the profession and medications risks coming across like a “ In our era, the experience of madness remains silent in the composure of a knowledge which, knowing too much about madness, forgets it.”1
Mark D. Green, MD
WestBridge Community ServicesReference
1. Foucault, Michel. Madness and Civilization: A History of Insanity in the Age of Reason, trans. New York: Vintage Books/Random House, 1965, 1988.
DR PIES RESPONDS TO DR GREEN
I appreciate Dr Green’s comments on my editorial, and I most certainly agree that we need to listen carefully and empathically to our patients. In my experience, most psychiatrists do just that; of course, as with any profession, there are unfortunate exceptions. It is difficult to respond to Dr Green’s contention that psychiatrists have been unwilling to “take responsibility for the harm we have caused and continue to cause,” since Dr Green does not specify what “harm” he imputes to psychiatrists. Nor does he specify what “abuses” he associates with psychiatry.
Of course, I’m aware that some patients have been inappropriately medicated, or have been denied a process of fully informed consent. Such failures are notable, and we must indeed take responsibility for them. But these failings do not justify the nihilistic and hateful rhetoric that sees all psychiatrists as predatory jailors, intent on “drugging” their patients-this was the rhetoric I sought to challenge. I believe that the vast majority of psychiatrists are conscientiously doing their best to help their patients, often under very adverse circumstances.
As for Foucault: I’m afraid I find very little instruction in his book, Madness and Civilization, from which Dr Green quotes. It is true that Foucault’s concepts of “epistemes” and “discourses” shed some light on how language may become a vehicle of power-and this is certainly germane to my editorial. But Foucault’s claim that “…all disciplines-be they scientific, legal, political, or social-operate through a network of self-legitimizing power and knowledge…”1 becomes a self-refuting argument. That is, there is no reason for us to believe that Foucault’s own claims are anything other than a self-legitimizing grab for power-power over the field of psychiatry! This self-nullifying aspect of Foucault’s arguments is also true of most “post-modern” arguments against any objective truths. Furthermore, as Ian Hacking writes, “Despite all the fireworks, Madness & Civilization follows the romantic convention that sees the exercise of power as repression, which is wicked.”2
I think Dr Green and I would agree that we psychiatrists must exercise great care in how we wield our considerable power; some, alas, have not been so careful. And yet, I still believe that, for the most part, we have used our powers humanely and with our patients’ best interest in mind.
1. Critical Theory. http://www.smpcollege.com/litlinks/critical/foucault.htm.
2. Hacking I. The archaeology of Foucault. In: Hoy DC, ed. Foucault: A Critical Reader. Oxford: Blackwell Books; 1986.
Leucht S, Corves C, Arbter D, et al. Second-generation versus first-generation antipsychotic drugs for schizophrenia: a meta-analysis.
Ghaemi SN, Shitzadi AA, Filkowski M. Publication bias and the pharmaceutical industry: the case of lamotrigine in bipolar disorder.
Medscape J Med.
Pies R. Should psychiatrists use atypical antipsychotics to treat nonpsychotic anxiety?
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Mojtabai R, Olfson M. National trends in psycho- therapy by office-based psychiatrists.
Arch Gen Psychiatry.
Schmidt HD, Duman RS. The role of neurotrophic factors in adult hippocampal neurogenesis, anti- depressant treatments and animal models of depressive-like behavior.
Geppert CMA, Roberts LW, eds.
The Book of Ethics: Expert Guidance for Professionals Who Treat Addiction.
Center City, MN: Hazelden; 2008.