Sympathy for the psychiatrist

Robert Whitaker writes in the current RSA journal that psychotropic medication is less safe and effective than is commonly believed. The use of antidepressant and antipsychotic medication is widespread, and Whitaker presents troubling evidence that taking these drugs can increase the frequency of relapse and reduce the chances of getting well and staying well. He presents evidence that patients who never take medication fare much better in the long term than those who accept medication early on. Whitaker is not alone in drawing attention to the unstable foundations of psychiatric prescribing.

The psychologists Richard Bentall and Joanna Moncrieff have both urged us recognise that the notion that psychiatric drugs correct imbalanced brain chemistry is a myth. It is a myth that has taken hold in the public consciousness to a very great extent.  Moncrieff, like Whitaker, explains that these drugs in fact do no such thing. The drugs act on our brains in such a way as to make them function differently and in doing so change the way we feel. Moncrieff explains that these medications produce drug-induced states which mask or suppress emotional problems. She does not say that we should stop using them, but suggests instead that patients should consider whether they want to use them with greater awareness of how they work.

This is tricky territory for non-experts like me to negotiate. The public misconception that mental illness is caused by brain chemistry being out of kilter is one problem. The poor long term outcomes for patients prescribed psychiatric medication is another. The fact that some patients’ severe suffering is ameliorated in the short term by the use of such drugs cannot be denied. It is clear that the issues raised by conflicting evidence in this field are very concerning, and the voices drawing attention to them are becoming louder and more numerous.

The overall effect is of an attack on the orthodox methods of contemporary Western psychiatry. The principle labour of psychiatrists has become to diagnose and prescribe, and medication is the first line treatment for the majority of patients who come under their care. As evidence builds that such medication is neither a cure, nor always a benign intervention, there is a danger that psychiatrists get demonised as unthinking peddlers of poison. A couple of weeks ago I wrote about the problem of the stigma of mental illness. It might not make me popular, but I do have some sympathy for the psychiatrists and wonder whether they are also becoming stigmatised.

The overall effect is of an attack on the orthodox methods of contemporary Western psychiatry.

It is important to remember that psychiatry is a relatively young discipline. There remains an awful lot that is yet to be discovered about what really causes mental illness, and some of the exciting action in the psychiatric field is in neurobiological and genetic research. But it is also in the psychosocial arena, as the importance of social connectivity, mindfulness and physical exercise become ever more apparent. Although it is clear that the drugs being routinely prescribed are in some ways rather clumsy, don’t work for everyone, and bring with them unwanted side effects, it is not the case that they are exclusively bad, or that they are dished out in bad faith.

The evidence that the drugs might worsen long term outcomes is worrying, but we must remember that this is relatively new evidence and that it takes time to acquire and properly analyse. However, there is a danger that psychiatry has already painted itself into a corner whereby it is only capable of regarding mental illness as a set of neurobiological components with the driving aim being to separate and identify them, and then develop the correct psychopharmacological intervention. So while it is an exciting time for psychiatry, it is imperative that psychiatrists take this opportunity to extricate themselves from the clutches of Big Pharma, and open themselves up to the possibility that drug-based treatment should no longer be the first port of call. If they do, then I can envisage a future in which patients are sufficiently informed and reflective to confidently demand to be supported through episodes of mental illness without medication, and psychiatrists become more holistic, discerning and flexible in their approach to treating their patients.