This is the Fourteenth in the Persecution Series, after The Persecution of Heretics, The Persecution of Vulnerable Adults, Harassment from the BBC to GMC, Harassment from Rolf Harris to James Coyne to Doctor Who, Persecution: Black Riders in the Shire, Persecution: Rumbles from Mordor, and eight in the SUI Cide Series SUI Cide in Betsi, SUI Cide Trick or Treat, The SUI Cide Note, SUI Cide or Homicide, SUI Cide in the OK Corral, SUI Cide & Peace in our Time, The SUI Cide Apparatus. A new subseries, the Pharma series begins next week.
For some of us, the magic of boarding an Alaskan Airlines flight from Anchorage to Atlanta with 200 other people and all their baggage, or even bigger planes aiming at crossing 12000 miles of Pacific Ocean, and finding that the thing actually lifts off the ground never fades.
Any sane thinking person should be reduced to a state of gibbering panic for the duration of the flight, but most of us put our trust in the woman at the controls and in the fact that if we don’t get there she won’t. If she had significant concerns she wouldn’t now be taking off. While aviation safety systems aren’t perfect, if the near misses or other glitches she and her colleagues report aren’t taken care of, no one gets anywhere until the problem is sorted because she won’t fly.
Riddle me this: Why take poisons?
When it comes to healing, there are lots of people who can offer you wise advice about your health and some can do a great deal of healing – people from our grandmothers through to life-style coaches, and pastors.
A wise doctor used to be someone who knew that varying rates of development were almost the definition of childhood and the best medicine was often simply reassurance, someone who rarely prescribed during pregnancy, someone who knew enough about life so that when faced with a woman apparently unhappy after childbirth would probe the state of her relationship with her husband rather than assume there was anything wrong with her hormones – but a good grandmother knew most of this.
This is the kind of wisdom we hope a good doctor might have, but none of it is unique to medicine.
What is distinct about medicine is that if you take certain problems to a doctor you are taking them to someone who has the option to poison, mutilate or shock you. The magic of medicine lies in something as counter-intuitive as getting a jumbo off the ground – in this case bringing good out of the use of a poison, or a mutilation.
If there is to be a magical moment when medicine lifts off, it used to come from the doctor at the controls but more often now comes with a doctor and patient co-pilot in the cabin – it does not come from a poison or a mutilation. Poisons are just poisons. Female Genital Mutilation is a mutilation.
Almost by definition then a good doctor has to be someone who knows when not to poison or mutilate or someone who, when things go wrong, can quickly respond with “what do you know, we gave you a poison and you’ve been poisoned, let’s see if between us we can work out where to go from here”.
But unlike a pilot, when doctors have a near miss or spot problems after giving you a poison, their views are regarded as anecdotal and are binned. Rather than support their colleagues, and refuse to use the new poison until the problems are sorted out, other doctors are liable to turn on anyone concerned about safety and accuse them of jeopardizing patient safety or medicine itself by reporting their observations.
Call me Ella
It’s common to dismiss psychiatry as the Cinder Ella specialty.
A recent past-president of the Royal College of Psychiatrists, Dinesh Bhugra, at a meeting in Hay-on-Wye in May, delivered the typical unthinking mantra when he said that psychiatry was attempting to join mainstream medicine and would get there sometime soon. We’ve been supposedly about to join the rest of medicine since the introduction of modern psychotropic drugs in the 1960s.
In fact psychiatry was the first to have specialist hospitals, and the first to have specialist journals. With Philippe Pinel in 1809 psychiatry was the first to outline the principles of evidence based medicine. Starting from the most complex clinical problems there are, Pinel was the first to show that differential diagnosis counts and other early psychiatrists followed up by distinguishing among mood disorders and psychoses in a manner that quite astonishingly stood the test of time when more specific treatments were later introduced.
The form of the randomized trial now most widely used in medicine was first used in psychiatry and psychiatry was the first branch of medicine to submit most of its treatments to controlled trials.
The talk at the moment is of Future Hospitals which will be in the community – closing the big old behemoths. Psychiatry led the way on this and on working in multidisciplinary teams forty years ago. The rest of medicine is catching up slowly.
More recently it has been the first branch of medicine to have substantial amounts of its literature ghost-written. It was the medical arena in which pharmaceutical companies first developed their abilities to sell diseases. It was the first to have professors in jail for putting non-existent patients into clinical trials. It has provided the poster-boy for medical conflicts of interest – Charlie Nemeroff.
Ticket to the ball
Psychiatry is the Sister who has got to the Ball first time after time and got her man. But this time the Prince seems completely uninterested. The options – suicide with a glass sliver or turn into an Ugly Sister?
If not one of these two options, psychiatry has to achieve another first. Its task is not, as the current President of the Royal College of Psychiatrists in Britain would have it, to get more psychiatry to people. Its task is to get to a position where people recognizing a real benefit might in a truly voluntary manner seek out psychiatric input. It has to find if there is anything about it, other than its police function, that can’t be provided by a good primary care generalist or a psychotherapist. It has to find true love.
When a surgeon makes a mistake it’s difficult to hide the consequences. A dead patient or one reduced to vegetable status. Having to meet the families of either the dead or the maimed is a reality check. While surgeons are often caricatured as arrogant, as Henry Marsh’s beautifully written Do No Harm shows failures like this temper surgical arrogance and in the best surgeons produce humility and sometimes significant anxiety.
In some but not all areas of medicine, the poisons we use come close to producing treatment induced disasters as clear cut as those facing surgeons.
There are problems when it comes to semi-disorders like osteoporosis where drug treatments may produce the fractures that the disease supposedly also produces. These do not offer the clear reality check that came with traditional medical poisoning and mutilation.
The problems with treatments that do not provide a clear reality check come to the fore in psychiatry. Depression can produce suicidality but so too can antidepressants. Psychosis can produce hallucinations but so too can antipsychotics or antidepressants. Almost all our treatments demoralize, enervate, and blunt. We simply don’t recognize these realities. This is close to psychotic. Next we’ll be thinking pumpkins are coaches.
Water into wine into antidepressant?
A good doctor can do marvelous things with treatments like the antidepressants or antipsychotics. But a doctor this good would also be able to do wonderful things with alcohol.
If alcohol were a newly discovered molecule that could be patented, it would be entirely possible to get alcohol on the market as an “antidepressant” or an “anxiolytic” putting it through the hoops that the SSRIs were forced to jump through – 6 week trials, where all we had to do was show marginal superiority compared to placebo using rating scales as outcome measures, and where we could hide the trials that didn’t work and hide the data from all trials.
Putting people, especially women of child-bearing years, who are pharma’s target market for psychotropic drugs, on alcohol chronically would be a public health disaster. But this is exactly what doctors, led by psychiatrists, have done with the SSRIs.
The State doesn’t interfere with your management of the risks of alcohol but it makes SSRIs available on prescription-only because we have every reason to think they will be more dangerous than alcohol, and yet doctors have all but been forcing these drugs on people against their patients better judgment.
Psychiatry in wonderland
Psychiatry however is a unique state of being whose inhabitants never have to say sorry.
It’s doubtful if any psychiatrist, or President of a professional body in psychiatry, has ever said sorry for more than a minute fraction of the suicides, homicides, miscarriages, or birth defects triggered by antidepressants. It’ll be a surprise if anyone owns up to the mental handicap, learning disability or autistic spectrum disorders that emerging evidence now compellingly links to treatment with antidepressants.
And if they don’t own up to clear cut things like this, what chance they will get to grips with the demotivation caused by antipsychotics, the permanent obliteration of sexual function that SSRIs can produce (Female Genital Poisoning), or the bewildering variety of problems linked to anticonvulsants?
The approval and marketing of the antidepressants is of debatable legality. The statute calls for the approval of drugs that have been demonstrated to be effective. The regulators have made it clear that the studies that were done to get these drugs on the market have shown an effect but not effectiveness. There is no evidence of lives saved or people back to work which would be most people’s idea of effectiveness. There are minor changes on rating scales completed by doctors that on a wishful thinking basis can be taken as hints that the drugs might work. But patients also completed rating scales, and their rating scales show no benefit at all – the data has been left unpublished.
The path of true love never did run smooth.
Suicide with a glass sliver
Psychiatry can, like Werner von Braun, say that’s not our department. But it’s not the regulators or even companies who strap people onto these unpiloted drones and send them on their way.
We don’t want every psychiatrist to go down with the ship and retire from practice or commit suicide if a patient commits suicide or to take into their care the patient with an autistic spectrum disorder born to a mother he has put on an antidepressant while pregnant, but we don’t want Korean ship captains either.
Banging on about the benefits of drugs like the antidepressants and refusing to acknowledge their hazards is a recipe for professional suicide. If the drugs work so well and are so free of problems, who needs psychiatrists? A good nurse could do the job more efficiently and a lot cheaper.
If the magic lies in the drug, who needs magicians?
The ugly sister
It may be the reason psychiatry hasn’t managed professional suicide just yet is because of its growing police function. As part of an increasing turn to risk management in healthcare, an ever greater number of patients are being legally detained, and put on community treatment orders, or illegally detained under a variety of Protection of Vulnerable Adult or related maneuvers.
Back in the 1970s or 80s when most of the current leaders of the profession entered the field, it was on the back of a promise that, while we might have to lock up some people temporarily in their own interests, broadly speaking our role was about facilitating growth and supporting people in their efforts to secure freedom from oppression. Few if any people entering the field could think this now.
Back in the 70s, we were concerned that legitimate protest was being sedated in the suburbs with benzodiazepines. Now the message to women with issues is to take SSRIs to empower yourselves and stop disturbing us.
Psychiatry has been a master of reinvention – like Moriarty in the Sherlock Holmes stories. To a much greater extent than it has realized, it has led in both good and bad developments in medicine. But do we really want to lead medicine down this path?
What instincts might lead someone into a profession whose mission is to control behavior and who doesn’t recognize a poison as a poison?
You’d be surprised:
“He who would do a great evil must first persuade himself he is doing a great good.”