Generalists and Partialists

February, 13, 2017 | 18 Comments


  1. I have made many a point about doctors prescribing antidepressants – and my disagreement with that situation. I still hold that view! If GPs were NOT prescribing these drugs then some alternative form of support would, by now, be common place. The prescribing of these drugs is an easy way out for GPs – and the right to place them on repeat prescriptions adds to the problem.
    I have not, at any time, said that psychiatrists would be any better – but my expectation would be that their knowledge would be more expansive. That dream has been shattered!
    The main problem, as I see it, is that GPs are expected to hand out medications that we use and are made better by doing so. They hand out the slip for antidepressants in exactly the same way – which catches us off-guard. Usually, an antidepressant will be handed out as “something to help you whilst we wait for an appointment with the secondary care team” – given as easily as if handing out a lozenge “so we can see if you really have a throat infection”.
    At least when we arrive at the psychiatrist’s appointment, we surely realise that any medication given here is, indeed, serious stuff. Our respect for the medication and, maybe our outlook, is different. No longer do we go merrily along as if we had simply been given a cough sweet – we actually appreciate that there may be side-effects to note here. We begin to appreciate that we can’t suddenly ditch these medications without problems.
    Maybe we, the patients, are the ones at fault here. Perhaps we need to start appreciating the dangers of ALL medications – whoever has prescribed them. Maybe we need to help the GPs along – by suggesting that, thanks all the same, but we won’t have a prescription. No, instead we’ll have our ten minutes’ worth of discussion on the best way forward with our ailment without resorting to drugs. I can already picture the GP’s facial expression if this were the case!
    To close – it isn’t the suitability of the prescriber that I’ve ever questioned but rather the suitability of the strength of medication being prescribed. That, and the nonchalant way that they are handed out.

    • I feel if you need to be on medication for a long time then better monitoring is needed, whom is prescribing the medications, or even better still more alterative therapy could be a better option so that mediation is only used where is needed.
      Also more education to the public about mental health, and more support groups , such has hearing voices groups, and day centres.

  2. I think the main point to take from this Generalists and Partialists is that looking in to the future the semi-robotic nature of the Goats may decrease rather than increase and the Sheep may rise up and kick the goats in to the long grass..

    I am not in favour of either/or at present and it will be fascinating as to which way this will go as there are too many anomalies with your ‘known’ doctor who is not known and whose own development did not develop in line with the 21st Century Patient who is increasingly aware of pharma tricks of the trade before the doctor picked up..

    ‘All animals are equal, but some animals are more equal than others.’

    Animal Ph/Farm

    Bible verses about Judas Goat

    (From Forerunner Commentary)
    Matthew 25:32-33

    Christ concludes His interpretation of the parable in verse 46, where He indicates that the sheep are given eternal life, but the goats are cast into the Lake of Fire. It is clear from this section of Scripture that we want the attributes of sheep and not those of goats!

    What is it about goats that causes God to use them in such a negative light? Goats are capricious. They are impulsive and unpredictable, devious and contrary. If they are not poking their heads through fences, they may be standing on their hind legs, stretching for those tender leaves just out of reach. Goats are never content with what they have.
    They are experts in opening gates and squeezing through small gaps because they hate to be confined. Fences that will handle sheep, cattle, and horses will not hold goats. They will work tirelessly to spring themselves from any situation they deem inhibiting.

    Consequently, goats are not very good followers. “Gregarious behavior” is a term that refers to the flocking or herding instinct which is found strongly in sheep, cattle, and horses. Again, this quality is rather weak in goats; they prefer leading or going off on their own. Meat packers use this instinct in sheep and goats to their advantage. They will train an old goat, appropriately called a “Judas,” to lead sheep to the pens for slaughter. A well-trained Judas will lead group after group of sheep to the slaughter all day long.

    A sheep follows its Shepherd, peacefully moving forward with the flock. He is content to be led because he has faith in Him. A sheep responds to his Shepherd’s voice and goes where He directs. On the other hand, a goat follows only its own lead, creating disunity when he comes in contact with others in the flock. Because of his independent nature, he often finds himself in contention with the Shepherd for leadership of the flock, leading some astray. A goat often eats things—a symbol of ingesting spiritual instruction—sheep would avoid because they have no real value and cause sickness.

    Goats are not inherently evil, but some of their traits could be deadly—spiritually—if found in a Christian. A Christian who is unpredictable, who thinks he is above it all, who independently does his own thing, who wants to take over, has trouble functioning in a group, or does not want to be led, is exhibiting the characteristics of a goat—one Christ says will be cast into the Lake of Fire!

  3. What a brilliant post Dr Healy, thank you! It says exactly what so many of us have been feeling, for SO long. Mary’s response is superb too.

    When we (husband or me) have to see a doctor or practice nurse (very rarely) for some routine procedure, like having our ears de-waxed or something equally unexciting, we are always asked what medications we are on. We are respectively in our late 60s and 70s. When we say, “oh, we don’t take anything except the odd paracetamol for headache or muscle pain” they look at us with incredulity, almost pity.

    I guess you could say we’ve been lucky not to need strong medication, but it has often been prescribed for us, but we’ve politely refused the prescription. We’ve tried to do what Mary said, use the consultation for 7-10 minutes good advice, often saying. ” could you tell us doctor, in the old days before these medicines, what would have been used?” Then we go with that to see if we can, for a week or two resolve things in a more natural way. I am sure we are seen as nuts. However, we watch the other patients of our age hobbling around the waiting room, many now very obese, no spring in the step, definitely not bright eyed or bushy tailed. Off they go with bags of boxes of meds from the in house pharmacy. The regular visit to the GP seems like a badge of honour.

    Don’t get me wrong, I have great sympathy for them, because I can’t help wondering if they would all have become so obese or infirm if they hadn’t begun taking meds routinely. And illness strikes out of the blue, unasked for. There’s a lot of luck in this. But drugs can make it so much worse. Particularly the antipsychotics and SSRIS, and the opioids. People don’t realise what these medications are doing to them, and probably, by now, they’d feel they couldn’t/wouldn’t want to, live without them. And the doc wouldn’t know how to talk to them to, literally ‘change the script’. It’s all too late. Only NHS Budget Cuts will ever begin to alter this. It’s become a habit, a way of life.

    Speaking personally, in a way, I would absolutely love there to be a magic pill to take away the terrible aching sadness and worry I feel when I wake each morning and remember that our dear son has died and we are now totally alone in the world. I used to have the odd glass of wine in the evenings, which helped a bit, but when it wears off the memory floods back. Life is a bummer sometimes, for most of us. I don’t know what the answer is for me, probably there isn’t one, but I can walk and look at nature, which will go on, in beauty, long after I am gone, and was there when I arrived on this earth. I can listen to music, and if motivated, I can write and paint and remember happy days with my children, long ago. I can try to count my blessings, like keeping warm, not starving, etc. But, like the Buddhists say (I think?), your body is a temple, it’s the only one you’ve got, and you owe it to yourself to be discerning about what you eat, and, even more importantly, what you trust others to tell you is good for you as medication for any ailments. Doctors are not mother/father substitutes to soothe and pat you on the head to visit regularly for comfort, they are people just like you, but who chose a different career, be they specialists or generalists, sheep or goats. Keep your headlights on, folks, and check everything. Trust no one blindly, or repent at leisure. Trauma strikes many of us and we feel like we are drowning, but reach out for the most reliable life raft you can. It’s rare that a pill or alcohol can save us for long. Other friendly caring people’s listening kindness can.

    • Heather, I feel that your last sentences -‘It’s rare that a pill………listening kindness can’. – say it all. Isn’t it true that there lies the truth of the matter? Be it generalist, partialist, nurse or pharmacist – if their info is given with genuine interest in your well-being, there is a fair chance that we’d soon be in a better place. The problems, as far as I can make out, are similar to those in any profession – except that, in mental health matters, there seems to be a separation rather than support between the different sections. I can only compare this to educational situations. When schools (in general) find that they have run out of ideas of how to further support a pupil, they call in an educational psychologist. The ed. psych. then assesses the situation and supports the school in their attempt to carry out his/her recommendations. The whole team is geared towards improving the lot of the pupil. It seems to me that, in medicine, the GP, once he can get the mental health on board, feels that the said patient is no longer a concern of his ( unless something physical crops up later). Coupled with this, the psychiatrist, in turn, sees this patient as his responsibility – shared with a care-coordinator – totally detached from the GP. I feel that this disjointed way of working has led to a fragmented service. Due to the way it works, primary care finds fault with secondary care for their lack of communication; secondary care blames primary care for the problems caused by their previous prescribing – no-one is ready to take full responsibility, which results in care without the necessary ‘listening kindness’ that could be so rewarding in many cases.
      Where the problem began, I do not know. Do GPs feel unsupported by the psychiatrists? – that is the feeling that I used to get in conversations with a GP, but whether that is generally true, I do not know. Do psychiatrists feel there is a lack of shared information from primary care? Quite possibly. Do both teams EVER discuss a patient’s progress so that it becomes a team effort? Most definitely not!
      When we look at this picture, is it any wonder that the pharmaceutical companies have managed to come along and divide matters even further? Maybe its time to forget about who does what and start working together – patients, carers, pharmacists, nurses, doctors and consultants – to ensure better care for the patient; giving the patient cause to celebrate the ‘joined-up care package’ created to provide all-round support for his/her recovery and continued wellbeing. By doing so, maybe the ‘Judas goat’ will become obsolete.
      I would just like to add that my comments regarding psychiatric support does not reflect the present care received. The GP IS now kept informed – how much this is appreciated is unknown as the GP does not see the patient … his medications are on a repeat prescription! Aargh!

  4. I agree, GP is less likely to be dogmatic. Less likely to continue prescribing an ineffective or harmful drug, to scare and threaten you into taking drugs, switching through an endless train of me too drugs, prescribing 2 anti depressant at the same time, adding an anti psychotic or other drugs, prescribe the “newest and best drug” (which is the most dangerous and expensive drug) etc.
    There’s no merit to those “psychiatric trends”, they are not based on evidence or logic.
    I think it’s related to the dogmatic “religious” nature of psychiatry.
    Some argue that GP shouldn’t prescribe psychiatric drugs cause they might misdiagnose, and give the wrong drug.
    One scare tacit is that a patient with latent bipolar disorder might get an anti depressant which would cause mania. But there’s evidence psychiatrist are better at recognizing supposed “latent bipolar disorder”, and they are far more likely to ignore a drug adverse affects, use higher doses and opt for one of those “psychiatric trends” – which are far more dangerous and probably much more likely to induce mania than anything a GP would do.

  5. I’ve just spent some time wondering who the Goats are – specialists or generalists. Both raise a wonderful picture…but if I’ve got the drift – the generalist – GP here in the UK – is most likely to know you as a person, and recognise (and not dismiss) a side effect as a side effect. In fact a lack of detailed knowledge of psychosis, agitated depression, manic states, bipolar 2 etc etc is likely to lead to a quicker diagnosis of drug induced illness rather than fulfilling a shrink’s (for example) pre-conceived ideas about what you are suffering from?

    I think that’s a really good analysis – just sadly undermined by the fact that right now, the way GP/generalist services have steadily gone, you are very likely to see maybe 8 – 10 different doctors over the course of an illness, depending on how many there are in one practice, and currently how many temporary locums are manning the barricades. Thus, even leaving aside the tick-box standard practising model, no one generalist is likely to have built up enough know-how about you to be able to detect a side effect. It is well nigh impossible here to see the same doctor twice running. I finally made headway with a GP back in 2012, when all kinds of hell had let loose, post-olanzapine (admittedly only after a bit of a barney) but he did start to listen and I had a kind of sense of being taken seriously. Trying to get an appointment with him regularly was a bureaucratic nightmare though – and then we moved anyway.

    But – more optimistically – there are really good challenges to tick-box medicine and ‘overmedicalisation’ going on. Margaret McCartney for instance (The Patient Paradox) who I think sits on the BMA’s panel trying to reduce the emphasis on medication and disease mongering. There are others too – OK maybe small voices but they’re there. Malcolm Kendrick who has been battling the statin war for an age. A couple of cardiologists who’ve challenged the ‘butter will kill you’ diktat. And judging by various friends and family who’ve been through cancer treatment recently, some oncologists are beginning to back off really aggressive treatment which gives maybe a couple of months extra life at the cost of any quality of life. But we all start off with a GP, so I think you’re quite right David – that’s where the curb on inappropriate prescribing will be most effective – and where raising awareness of side effects is crucial. However – I feel the urge to say I never ever forget the agony of severe depression and how desperately I wanted something to help. It’s a complex call.

  6. From personnel experience I can agree with this post, I myself had very bad experiences with psychiatrists within the NHS and CJS. It was the Retired Psychiatrists that were the most helpful, honest and independently intelligent of them all. Gp’s on the other hand I found to be either not aware (one third of them), protective of the system (another one third) but there was the last third of them I would say were more aware, astute and concerned as research and experience with patient regarding SSRIS contact comes in. I have met better GP’s than Psychiatrist to be honest.

    I think when it comes to SSRI drugs Gp’s do know just as much and are more likely to be more honest about side effects than Psychiatrists within the system.

    God forgive me for saying this but I view Psychiatrists now within the system as a form of governmental control when someone with mental health problems has no where else to go.

    I apologise if that is not the case as Im sure there are the odd few out there that are very good but from my own experience of them in the NHS ans CJS they were really terrible.

    I think this post is right they are better at diagnosis than looking out for side effects.

    • Interesting that Anne-Marie notes that Retired Psychiatrists were the most helpful, honest and independently intelligent of any she saw.

      Back in the 1960s and 1970s my mother and I occasionally saw the psychiatrists my father was being treated by. They were careful to keep his trust and not divulge any of his confidences to us but they were always cordial, they listened intently to our concerns, they were sympathetic, and did all they could to support us and him. They respected us ALL and acknowledged that we were living in a hellish situation, one that was grim for all of us. I was in my teens at the time, and I have to honestly say, it was really scary seeing my father change from depression to mania quite regularly, with all the financial worries that brought, as well as the personality change, from a quietly spoken loving man, into a turbo-charged extraordinarily different totally unreasonable person. My mother had given him her word, back in the 1940s when he first got ill, (after major heart surgery followed by the trauma of the death of yet another child due to polio), she promised never to send him away into a mental hospital again. His one and only experience there had been so terrifying for him. She was a nurse, her father and brother GPs. We did all we could to help him to manage these cycles at home, and keep working for as long as he could and wished to. This kept him grounded in normality as much as possible. It didn’t stop the embarrassed tittle-tattle in our village though, and carrying the stigma of being the child of a ‘mentally ill’ father. You never escape that, some folk even to this day are watching and waiting, (hubby’s siblings) to see if madness will eventually engulf me too! I’ve reached my 60s without it happening, but I am well aware of the need to behave with exemplary decorum at all times, no emotional outbursts, no crying at funerals when my parents died young, etc.

      My point is, like Anne-Marie’s, that in the old days, there was more joined-up thinking in psychiatry then, or seemed to be, or maybe they just had more time to think? I love Sally’s description of the GP locums ‘manning the barricades’ in her local Practice. SO true. We have to wait 4 weeks to see the GP we know best. However, if we push it, we can get a phone-back quick word with him/her within 2 days and if we can justify our need as urgent, s/he may squeak us in for an appointment within 2 weeks. He is well worth the wait. There are several there who definitely are not. But like I said before, we’ve been pretty lucky health wise on the whole. Not so easy for others.

      I do have fond memories of my father’s old psychiatrist, Prof Lindford Rees at Bart’s. He did what he could. He knew it was hard, but he tried. Our old GPs in those days were good too. They helped as best they could. They encouraged. Above all, they listened, they even offered safe haven, when things got truly desperate. Now we have such a different system, thanks to health, particularly mental health, becoming a ‘points system’. The Money Follows The Patient’. In management-speak, if you’ve got ‘Anxiety’ you only get, say, 3 points. If you are not recovered, on your meds and if lucky, CBT, within x number of weeks, you fall off the edge of the system. They haven’t time to fiddle about waiting whilst you heal, you must be being unco-operative or you’d be well by now. Good old well paid bureaucracy that modernised us all, with buzzwords and labels. I often wonder what Prof Lindford Rees would have made of that. But of course, that was in the days of human beings with thinking minds and compassion, not of blindfolded Goats leading Sheep to the slaughterhouse. If sheep WERE there in the old days, they trusted their caring shepherd, with due cause, because P/farmer profit wasn’t the driving factor. Oh, to turn the clock back!!

  7. Um, define “specialist”?

    The MHRA, a few years ago, rolled out the “SSRI Learning Module”, it was aimed at healthcare professionals. Part of that module stated that those (patients) who were experiencing severe withdrawal should be recommended to ‘specialists’. When I asked them for a list of said ‘specialists’, they couldn’t provide me one.

    The only “specialists” in the arena are current and former patients of said drugs – besides, what works for one person may not work for another.

    Wrapping a cold wet towel around my head helped me with the Seroxat zaps but it may not help someone else suffering from the zaps.

    In the case of SSRI withdrawal I think “tips” are best.

    I get a lot of emails asking about Seroxat withdrawal. I normally answer starting with… “I’m not a doctor, but…”

    Ironically, one patient once told me he had shown the “tips” I had given him to his GP – His GP responded with the customary, “Don’t believe everything you read on the internet or from conspiracy theorists.”

    And so the cycle continues…

    • Just as an aside – I suffered from a similar ‘head zap’ reaction as a withdrawal effect from taking a lemon balm and skullcap herbal remedy for mild transient anxiety. My head ‘zaps’ occurred with a with any element of surprise, for example, dropping a fork on the kitchen floor, and were accompanied by a ‘jumping out of my skin’ reaction, very similar (although not as extreme) to that seen in the ‘Jumping Frenchmen of Maine’ syndrome. I believe that this withdrawal side-effect was mediated through the GABA receptor sites for benzodiazepines – skullcap contains benzodiazepine-like compounds and I believe that lemon balm may too.

      So I wanted to warn anyone who was considering herbal remedies as perhaps a softer and safer alternative to prescription drugs that they may not be, they are drugs like any prescription medicine and may be equally or even more dangerous to take. I thought that I was being careful – I took far less than the recommended dose (3 to 5 times less), but I continued to take the remedy for a couple of months at this very low dose, not for anxiety but because it took away miserable chronic hip/buttock/thigh pain that I had been suffering with for a long time. I am a cautious person – I took the herbal remedy in the first place so that I could avoid the potentially harmful ADRs of prescription anxiolytics and anti-depressants and so that I could take a much lower dose than suggested, increasing the dose up the amount required for a therapeutic effect, but no more. (I didn’t need to, it worked to help my anxiety at the very low dose). There was no information on the bottle to say that it could be unsafe to continue to take the remedy, but after a couple of months I thought I should perhaps enquire as to whether continued use was advisable. There was no information available on this from the company or online so I decided that the safe thing to do was to stop. That was when my problems started, although I didn’t relate the two events straight away. I would far rather suffer chronic pain than suffer this awful side-effect. It took many years for the startle reaction to subside. Seven plus years on I am mostly unaffected but if there is a loud bang or large-scale sudden event then I still feel the remnants of it in my head.

  8. On the special expertise of modern psychiatrists: I can’t resist sharing a recent news item which poses the question: Really, how hard can it be?

    Scott Redman of Chicago, a guy without even a high school diploma, spent much of the last decade passing himself off as a psychologist and providing therapy at various south suburban clinics. In 2015 he pleaded guilty to one count of practicing without a license.

    Then he set his sights higher. Borrowing the name and identity of a local doctor, he hired on as a psychiatrist:

    “Over the next four months, Redman treated more than 100 patients. Armed with a DEA license he fraudulently obtained under Dr. Lopez’s name, Redman issued 92 prescriptions to more than 50 of those patients to treat psychiatric problems ranging from anxiety to panic attacks, prosecutors said.”

    A shocking act of fraud, right? And yet there was this:

    “Authorities did not allege that Redman’s recklessness caused serious injury to any patient, but the risk of that happening was real, prosecutors said.”

    The worst they could come up with was a statement from a college student who consulted him for depression and anxiety; she said Redman prescribed the wrong sort of antidepressant, making her depression worse and resulting in her taking a semester off school at his suggestion.

    Now, I do feel sorry for that sister. I’ve been in her shoes. Then again, I was under the care of proper board-certified specialists, who make that sort of mistake (and worse!) all the time. Prosecutors ridiculed Redman and his lawyer for claiming in a pre-sentencing motion that he “did the best anyone could for his patients,” but I wouldn’t rule that out.

    In fact, I can’t help but feel a tad wistful, thinking there was a Chicago shrink out there seeing 100 patients and only prescribing drugs for 50 of them. If only for a few months. Ah, Dr. Lopez/Dr. Redman/Scott Old Buddy. We lost you too soon.

    • Reading this, Johanna, has given me an idea. We all know that those unfortunate enough to have suffered horrendous reactions to these drugs have difficulties finding/keeping a job. Well, now then, how useful they could be to pass their ‘tips’ on to patients presently seen by psychiatrists for anxiety or depression? They could be available as ‘professionals by personal experience’ to sit alongside a psychiatrist, to support a patient ( or client or whatever they are these days – I lose track!) who is suffering adverse reactions or withdrawal problems! Do you reckon it would work? I feel sure it would – don’t think ‘top of the tree’ would agree though!

  9. The Judas Gs..

    This is not an invitation to talk about vax, this was covered in a last post, it is just an example of how far you go to possibly get recognition when in your heart and soul you think that you are right and so many are wrong..

    Seamlessly murdered…an example of G and P and the stampede of our own personal crusades battling the animosity rather than any Scientific Data..

    MMR fraud doctor’s film was shown under cloak of secrecy

    David Robert Grimes ‏@drg1985 Feb 14

    David Robert Grimes Retweeted David Robert Grimes
    Suppose @DrWakefield (actually ‘Mr’) has to seek admirers somewhere – scientific community wouldn’t piss on him were he on fire.

    Ben Goldacre called out Bob as an ‘Angry Smeary Conspiracy Theorist’

    What does language tell us and how important is it to respond like with like or does that run the risk of further alienation..

    I knew the power of these people during and after when I was subjected to more hostility than I had ever seen in my life which is why there was no choice but to walk away. If I had started fighting back as I knew I should, I knew that the repercussions could affect more than just me and so I went in to protective mode on their behalf, but, unfortunately this meant I had sacrificed my own place and the battle of all battles to keep up the strength to carry on from where they had dumped me..has never really stopped..

    For crying out loud ‘there you are, I told you she was unhinged’.

    Club 329: Part 1
    June, 7, 2016 | 26 Comments

    David Healy says:
    July 1, 2016 at 4:00 am

    What do you make then of GSK’s many links to Ben G and in the light of that his apparent efforts to act like Study 329 never existed?

    The language is unified on our part and doesn’t rather a lot hinge on the strength of the language of others which belongs to those who use it?

    A Goat can be recognised by its ‘bleat’..

  10. How ‘The Mighty’ has fallen..

    BetterLife February 17, 2017 at 12:07 am

    Good blog post on a skirmish with #medicatedandmighty by author Laurie Oakley.

    @truthman30 also blogged about the company and the hashtag during the hashtag event. The vituperative feedback in the comments was as expected.

    “I swung in to hero and cop mode:”

    You certainly did, Laurie.

    Well done!

    The Mighty T30 and The Mighty Rxisk..

  11. Passions running Boot Camp..

    Dr. David Robert Grimes on Jeremy Vine…….toe-curling .. with Magda..

    At 35.33 mins

    The Times today with more ‘quotations’ from the Scientific Community..

    Edzard Ernst, professor emeritus of complementary medicine at Exeter university, said: “Any company or person trying to make money by alarming people and thus endangering public health is not just unethical and immoral but also despicable and irresponsible.

    “Wakefield’s data has been shown to be wrong. That he still insists on discouraging people from getting vaccinated is disturbing and a risk to public health. I just hope that the British public recognises a charlatan when they see one.”

    52 minutes ago
    I am just so fed up of The Times’ continued vindictive vendetta against Andrew Wakefield. It is at odds with every principle of intelligent impartial journalism. The language used is unnecessarily inflammatory, and this petty and puerile approach does not belong in this paper. Brian Deer’s personal attacks on Andrew Wakefield just became increasingly embarrassing to read, and it is absurd to perpetuate them. Just stop it please.


    Katinka Blackford Newman
    · 15 February at 18:28 ·


    Have you become violent or had violent thoughts on an SSRI antidepressant and would be filmed as part of a major UK investigative documentary with international cases. Please email me at but only if you are happy to be identified.

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