A patient's right to self-discovery

[chiron89]

I don't know what the "feedback" is? You don't want a diagnosis? Is that it?

Sorry, I completely misread your post and am deleting my response since it's definitely out of line.

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[chiron89]

The best way to get respect is to give respect. That goes both ways.

I always try to give respect to people whose tone, empathy, and patience impress me. I think that ethical issues that affect millions are good justifications for debates. An unfortunate consequence of debates is that often people's emotions run high.

 

[sunlioness]

OK. I'm going to take a step and speak with some authority.

Psychology is a wonderful, beautiful, and valuable science. But until it heals its own divisions, there are patients who will be hurt and burned by those divisions.

The system in America whereby CBT and pharmacotherapy are given almost exclusive authority over the field, actually hurts a lot of people. Mostly patients. But also psychologists whose opinions differ.

Which one are you?

 

[sunlioness]

I'm really tired of coming online and seeing constant messages on the theme of "how and why doctors suck". I really am. And it's especially grating to see that attitude expressed here.


Sent from my iPad using Tapatalk

 

[erg923]

That sounds a little snotty. I never asked for a diagnosis..

I didn't ask for my hypertension dx. But guess what, that's what I got. Your doctors don't need your permission to render a diagnosis. Silliness.

Your orginal topic seemed to be based on the notion that dx is somehow related to self-discovery and somehow hinders it (I guess?), I concept that neither myself nor anyone else here has really ever even understood. You gonna spalin that?

So far, all you have really said (repeatedly) is that you love and respect psychology (yet you posted in the psychiatry forum), but want it to be more....Im not sure what. No one understands what you want, or what your question actually is.

 

[erg923]

I always try to give respect to people whose tone, empathy, and patience impress me.

Can I show this to the Garrison Commander here on base?

 

[hamstergang]

An unfortunate consequence of debates is that often people's emotions run high.

What I see more of is frustration in trying to understand what you're saying. You have been so vague and cryptic that there's not much of a debate yet. If you'd explain where all this is coming from and be more concrete then maybe we could get something going.

 

[675015]

This thread is confusing and hard to read.

 

[chiron89]

What I see more of is frustration in trying to understand what you're saying. You have been so vague and cryptic that there's not much of a debate yet. If you'd explain where all this is coming from and be more concrete then maybe we could get something going.

Thanks for the feedback. I'll describe a couple complaints in bold to get going.

Psychiatry is lacking a clear definition of malpractice
Surgeons, primary care doctors, dermatologists, GI doctors, and plenty other sibling fields all operate with a responsibility to provide helpful, adequate treatment. There are standards of adequate treatment and harmful treatment that allow patients to file malpractice suits and receive reimbursement when deserved. The legal punishment for malpractice, while proving a nuisance in the case of unjustified lawsuits, also sets a standard of treatment that physicians strive to meet. This standard acts as a deterrent when the physician is not confident that they can treat the patient adequately, leading to a referral. Since psychiatry does not have an adequate definition of malpractice, or a clear procedure whereby patients can report malpractice, short of sexual abuse, there is simply **not enough** to deter a psychiatrist from treating a patient when they lack the confidence and competence to do so. I think this is partly why there is less dialogue and referral between the different branches of psychotherapy. The deterrent of malpractice is central to ensuring adequate treatment and proper referrals.

Are chemical imbalances cause or effect? This is not provable.
We cannot prove that a chemical imbalance is a cause of a person's lifelong anxiety/depression or an effect. It might perpetuate symptoms in the short term, but not be the cause in the long term. I personally suspect that chemical balances are often a symptom and not a cause. I think that sometimes our unconscious minds are the real cause, and an adequate grappling with the unconscious is the only long-term solution. Since psychology and psychiatry cannot say with certainty that they know the answer to this question, the fields have an ethical responsibility to admit they do not know, and not base treatments on a false premise. Before responding, please note the careful wording. I acknowledge that chemical imbalances might very well be real (and probably are). But I argue it's unprovable that they are the cause and not the symptom, especially in the general case of anyone who's had long-term anxiety or depression.

 

[chiron89]

Can I show this to the Garrison Commander here on base?

That's funny.

 

[splik]

yes but what has this got to do with what you were talking about? Also many psychiatrists don't believe in "chemical imbalances" or aren't interested in these pseudoscientific theories of mental illness that have become popular in recent years. I am sure psychologists are even less interested. There is no definition of malpractice in any specialty. There are simply standards of care - and if these standards are breached and they lead to harm, that would constitute malpractice. I think you will find things are woolier than you might like to believe in many specialties (like peds, ob/gyn, surgical specialties) as much of medicine is an evidence free zone. However you are correct that in the US at least, the professional bodies are much more interested in serving their members and their own interests that setting standards in the field. This is unfortunate, as there are no clear guidelines for the management of many mental disorders, which mean that practitioners are largely unencumbered from guidance about which therapies or treatments they can use which does a disservice to our patients. I think this is a legitimate criticism but I am failing to see what it has to do with the original question in this thread.

 

[chiron89]

yes but what has this got to do with what you were talking about? Also many psychiatrists don't believe in "chemical imbalances" or aren't interested in these pseudoscientific theories of mental illness that have become popular in recent years. I am sure psychologists are even less interested. There is no definition of malpractice in any specialty. There are simply standards of care - and if these standards are breached and they lead to harm, that would constitute malpractice. I think you will find things are woolier than you might like to believe in many specialties (like peds, ob/gyn, surgical specialties) as much of medicine is an evidence free zone. However you are correct that in the US at least, the professional bodies are much more interested in serving their members and their own interests that setting standards in the field. This is unfortunate, as there are no clear guidelines for the management of many mental disorders, which mean that practitioners are largely unencumbered from guidance about which therapies or treatments they can use which does a disservice to our patients. I think this is a legitimate criticism but I am failing to see what it has to do with the original question in this thread.

Misdiagnosis and mistreatment do a lot to hurt a person's quest for self-discovery and self-esteem. It can set people back many years before they can confidently hold conversations with others, and have a good view of themselves. When a dermatologist mistreats acne, they cause a headache for the person but they don't create demons. The issue is more intense in psychiatry because there is a great risk for harm and little accountability. The consequences of malpractice are much less visible, then say, a failed heart surgery. To touch on a sensitive topic, there are suicide risks to over-prescription or wrong prescriptions. But there are few if any malpractice suits.

 

[splik]

Misdiagnosis and mistreatment do a lot to hurt a person's quest for self-discovery and self-esteem. It can set people back many years before they can confidently hold conversations with others, and have a good view of themselves. When a dermatologist mistreats acne, they cause a headache for the person but they don't create demons. The issue is more intense in psychiatry because there is a great risk for harm and little accountability. The consequences of malpractice are much less visible, then say, a failed heart surgery. To touch on a sensitive topic, there are suicide risks to over-prescription or wrong prescriptions. But there are few if any malpractice suits.

I think it would be incorrect to say that dermatological malpractice does not create demons. If you mess up someone's acne treatment they could be horribly disfigured and catastrophically anxious or depressed, withdraw from the world, find it hard to have relationships with other people etc. Also some dermatological treatments for acne can cause psychotic depression and suicidality. There have in fact been suicides associated with acne and its treatment. Psychiatrists in the US actually face a real risk of malpractice suits just like other specialties. The reasons that we are less likely to be sued, and less likely to be successfully sued are more to do with the fact that we don't do procedures (with high stakes complications), we see fewer patients, we know our patients better, and we tend to have a better relationship with our patients (quality of the relationship has more to do with being sued than anything else). Some other reasons that may affect lawsuits are like you say the field is somewhat more nebulous so it might be hard to identify whether a breach in standard occurred (but this not really because of bad care, but the fact that for many problems our treatments are limited), patients with serious mental illness are less likely to be able to sue and may be regarded as "unreliable" or too disorganized to do so, and patients may fear what is exposed in a lawsuit (as all their personal problems will become public record etc).

The annual risk of facing a malpractice suit for a psychiatrist each year is 2.6%. Although that is low compared to other specialties, that is still very, very high and means that across a typical career most psychiatrists can expect to face a malpractice claim. Actually, I think the bigger problem is that the state medical boards often will not do much to bad psychiatrists in terms of their licensing (bad physicians in general) - but many of us are quite fearful of a malpractice suite, most of which are frivolous. Malpractice suits are quite common after suicide and usually there has been no malpractice.

 

[splik]

another ethical issue around malpractice, is sometimes judges feel wary about apportioning too much blame for suicides to psychiatrists (which rarely could have been prevented by the psychiatrist anyway), as they fear that psychiatrists will stop seeing suicidal patients for fear of litigation. In actuality it is quite common for psychiatrists to not see suicidal patients in their private practices because they fear litigation. Juries on the other don't think about these things, and usually if a case comes before a jury, they are likely to hold the psychiatrist accountable for the patient suicide even if the psychiatrist did everything they could.

 

[splik]

Misdiagnosis and mistreatment do a lot to hurt a person's quest for self-discovery and self-esteem.

That is true, but it's not malpractice. Correct diagnosis and treatment could also do that. A minority view within the mental health fields is that labelling a person with a mental disorder (and particularly a label like "schizophrenia" )is one of the most damaging things one person can do to another. Technically the diagnostic label may be correct but it could be very psychologically damaging for a person and erode their sense of self-esteem, efficacy and hope. This is probably one of the reasons why young intelligent men who have just been diagnosed with schizophrenia have a particularly high risk of suicide, and possibly one factor why the risk of suicide in those with the diagnosis is highest in the first year.

 

[PikminOC]

What I'm protesting is a lack of humility in the field which is evident in this thread. A good physician has a willingness to receive and empathize with feedback. I don't see that willingness reflected in some of the physicians here. Fifty years from now psychiatrists will be rolling their eyes at how many psychiatrists of today treated their patients. In the same way that psychiatrists of today roll their eyes at how the psychiatrists of fifty years ago treated their patients. This basic insight is what engenders humility among the best of the field. It takes the best of the field to realize the limits of the field. And that's why the best practitioners have humility, but not the rest.

Wow. Time to block this user.

 

[PikminOC]

What I see more of is frustration in trying to understand what you're saying. You have been so vague and cryptic that there's not much of a debate yet. If you'd explain where all this is coming from and be more concrete then maybe we could get something going.

I'm sure he knows what he needs. We stupid doctors wont give him 900mg Adderall for his self diagnosed adhd with additional history of crystal meth abuse..

 

[erg923]

Psychiatry is lacking a clear definition of malpractice
Surgeons, primary care doctors, dermatologists, GI doctors, and plenty other sibling fields all operate with a responsibility to provide helpful, adequate treatment. There are standards of adequate treatment and harmful treatment that allow patients to file malpractice suits and receive reimbursement when deserved. The legal punishment for malpractice, while proving a nuisance in the case of unjustified lawsuits, also sets a standard of treatment that physicians strive to meet. This standard acts as a deterrent when the physician is not confident that they can treat the patient adequately, leading to a referral. Since psychiatry does not have an adequate definition of malpractice, or a clear procedure whereby patients can report malpractice, short of sexual abuse, there is simply **not enough** to deter a psychiatrist from treating a patient when they lack the confidence and competence to do so. I think this is partly why there is less dialogue and referral between the different branches of psychotherapy. The deterrent of malpractice is central to ensuring adequate treatment and proper referrals.

Are chemical imbalances cause or effect? This is not provable.
We cannot prove that a chemical imbalance is a cause of a person's lifelong anxiety/depression or an effect. It might perpetuate symptoms in the short term, but not be the cause in the long term. I personally suspect that chemical balances are often a symptom and not a cause. I think that sometimes our unconscious minds are the real cause, and an adequate grappling with the unconscious is the only long-term solution. Since psychology and psychiatry cannot say with certainty that they know the answer to this question, the fields have an ethical responsibility to admit they do not know, and not base treatments on a false premise. Before responding, please note the careful wording. I acknowledge that chemical imbalances might very well be real (and probably are). But I argue it's unprovable that they are the cause and not the symptom, especially in the general case of anyone who's had long-term anxiety or depression.

Still dont follow.

Malpractice is legal term and that definition does not vary across fields.

Your second issue is about 20 years old. Don't get your psychiatry from pharm commercials.

 

[erg923]

Misdiagnosis and mistreatment do a lot to hurt a person's quest for self-discovery and self-esteem. It can set people back many years before they can confidently hold conversations with others, and have a good view of themselves. When a dermatologist mistreats acne, they cause a headache for the person but they don't create demons. The issue is more intense in psychiatry because there is a great risk for harm and little accountability. The consequences of malpractice are much less visible, then say, a failed heart surgery. To touch on a sensitive topic, there are suicide risks to over-prescription or wrong prescriptions. But there are few if any malpractice suits.

Has anyone here argued differently? Correct diagnosis is important, I agree.

But then you again, you started this thread by asserting diagnosis was a "slippery slope."

I would also agree that the "harm" looks different across fields. What's your point?

 

[deleted343839]

What I'm protesting is a lack of humility in the field which is evident in this thread. A good physician has a willingness to receive and empathize with feedback.

What you're giving here isn't feedback. Feedback usually refers to a person's specific actions and performance, whereas you're sharing a perception of an entire profession (two of them, actually). That perception seems to be shaped by incomplete or incorrect information. It's hard to engage with many of your concerns since they are predicated on ideas that not many of us actually share (eg, I'm not seeing anyone here standing up for the cause of biological reductionism).

 

[thoffen]

Psychiatry is lacking a clear definition of malpractice
Surgeons, primary care doctors, dermatologists, GI doctors, and plenty other sibling fields all operate with a responsibility to provide helpful, adequate treatment. There are standards of adequate treatment and harmful treatment that allow patients to file malpractice suits and receive reimbursement when deserved. The legal punishment for malpractice, while proving a nuisance in the case of unjustified lawsuits, also sets a standard of treatment that physicians strive to meet. This standard acts as a deterrent when the physician is not confident that they can treat the patient adequately, leading to a referral. Since psychiatry does not have an adequate definition of malpractice, or a clear procedure whereby patients can report malpractice, short of sexual abuse, there is simply **not enough** to deter a psychiatrist from treating a patient when they lack the confidence and competence to do so. I think this is partly why there is less dialogue and referral between the different branches of psychotherapy. The deterrent of malpractice is central to ensuring adequate treatment and proper referrals.

Psychiatric malpractice is not different than any other physician's malpractice. It rests on duty of care, dereliction of said duty, damages, and said dereliction being the proximate cause of the damages.
It does seem, however, that your main concern is in the quality of standard of care for psychiatrists (the dereliction piece). I agree that it is inadequate, but must admit that I am not really an expert on it. I do feel that the largest driver of said standards being hard to establish is the lack of clinically practical precise objective measures to guide diagnosis and treatment, and lack of quality evidence for said treatment. We are headed in that direction with measurement based care, and it comes with some positives, and it also endangers focus on the therapeutic alliance and things such as transference and counter-transference and individualized treatment plans which can be essential to helping many patients.

I do not agree that, even if significantly improved, the threat of malpractice is a useful clinical motivator for treating patients. It is my perception as a provider of care that concerns over liability harm patients and systems far more often than they help. I feel it is much more prudent to pay attention to the intrinsic rewards of providing good treatment instead of the fears of failing to do so.

Are chemical imbalances cause or effect? This is not provable.
We cannot prove that a chemical imbalance is a cause of a person's lifelong anxiety/depression or an effect. It might perpetuate symptoms in the short term, but not be the cause in the long term. I personally suspect that chemical balances are often a symptom and not a cause. I think that sometimes our unconscious minds are the real cause, and an adequate grappling with the unconscious is the only long-term solution. Since psychology and psychiatry cannot say with certainty that they know the answer to this question, the fields have an ethical responsibility to admit they do not know, and not base treatments on a false premise. Before responding, please note the careful wording. I acknowledge that chemical imbalances might very well be real (and probably are). But I argue it's unprovable that they are the cause and not the symptom, especially in the general case of anyone who's had long-term anxiety or depression.

As others have pointed out, these words cause most psychiatrists to cringe. We recognize that we treat complex illnesses which are not classified on clear biologic mechanisms, and likely represent spectra of illnesses with multifactorial in origin. Even our symptoms to diagnose such illness are subjective and culturally dependent and subject to interpretive change over time.

This does not mean that our systems are bad. Some standard systematic approach is essential to scientific discovery to advance our field, just as it is essential to any other field. At any point in time, we can only do the best that our evidence provides. Unfortunately, our evidence provides marginal benefits fairly often. What is cool, however, is that it is proven to provide benefit nonetheless. In the end, it also means that we must be prudent to separate from the system when it is clear that it is not working for the individual.

It is interesting, because 1 point appeals to greater systematization and standardization of care, and the second point leads to less. Yet they are both valid. Instead, I would suggest an improved systematized initial approach coupled with the flexibility to explore alternatives when the initial approach is not working.

While I recognize that the gist of your biological dilemma is unfortunate, and that it would be ideal to have a more solid biological basis for our diagnoses and treatments, this is merely a statement of the limitation of our scientific evidence which is likely to endure for quite a long time, perhaps forever. It does not, however, invalidate the field. Our treatments are proven to be efficacious, and we need not know why they are efficacious in order to utilize them. After all, if an old-fashioned TV is fuzzy, do you not bang on it until the picture clears?

What may be conflicting you is the limitations on efficacy and the risks with the treatment. I make no apologies for this. It is the state of things. All psychiatrists want better and safer drugs. We must weigh the benefits and risks of our treatment vs. the projected outcomes of not treating. This is where so many fail to recognize the need for what we do. It is not so important because our interventions are so successful and without risk -- it is instead because not treating serious mental illness is so often disastrous.

 

[Ceke2002]

You know I really don't get what's so difficult to understand here. @chiron89, whilst I'm hoping to enter an undergrad program in Psychology (and hopefully a Fellowship in Psychiatry post grad at some point), I'm also a patient who has been under the care of a Psychiatrist (mainly for psychotherapy based treatment) for the past 6 or so years. My Psychiatrist tends to work less within strict boundaries of diagnosis and more with the view of a patient's individual symptomology as being part of an overall spectrum to be looked at as a whole. Within reason he doesn't place judgments of 'good' or 'bad' on things like my opinions, points of view, individual traits that make me who I am as a person, self identity, etc, and he has never attempted to force, or imprint his own attitudes and opinions on anything conducted in therapy sessions that might be considered self discovery on my part. Having said that, it still doesn't mean that I haven't been given any sort of diagnosis whatsoever, or that the diagnoses I do have are not important. My Psychiatrist still needs to know when I'm having a recurrence of something like major depression, or relapsing back into former patterns of anorexia nervosa, or re-experiencing symptoms of psychotic features, so he can begin a targeted treatment plan sooner rather than later. It's no use me pretending I don't have any sort of diagnosis at all, or dismissing a diagnosis as unnecessary and unimportant, because let me tell you a recurrence, and potential non treatment, of any of my diagnoses does far more to interfere with any sort of concept of 'self discovery' than having a diagnosis does in the first place.

 

[chiron89]

Psychiatric malpractice is not different than any other physician's malpractice. It rests on duty of care, dereliction of said duty, damages, and said dereliction being the proximate cause of the damages.
It does seem, however, that your main concern is in the quality of standard of care for psychiatrists (the dereliction piece). I agree that it is inadequate, but must admit that I am not really an expert on it. I do feel that the largest driver of said standards being hard to establish is the lack of clinically practical precise objective measures to guide diagnosis and treatment, and lack of quality evidence for said treatment. We are headed in that direction with measurement based care, and it comes with some positives, and it also endangers focus on the therapeutic alliance and things such as transference and counter-transference and individualized treatment plans which can be essential to helping many patients.

I do not agree that, even if significantly improved, the threat of malpractice is a useful clinical motivator for treating patients. It is my perception as a provider of care that concerns over liability harm patients and systems far more often than they help. I feel it is much more prudent to pay attention to the intrinsic rewards of providing good treatment instead of the fears of failing to do so.



As others have pointed out, these words cause most psychiatrists to cringe. We recognize that we treat complex illnesses which are not classified on clear biologic mechanisms, and likely represent spectra of illnesses with multifactorial in origin. Even our symptoms to diagnose such illness are subjective and culturally dependent and subject to interpretive change over time.

This does not mean that our systems are bad. Some standard systematic approach is essential to scientific discovery to advance our field, just as it is essential to any other field. At any point in time, we can only do the best that our evidence provides. Unfortunately, our evidence provides marginal benefits fairly often. What is cool, however, is that it is proven to provide benefit nonetheless. In the end, it also means that we must be prudent to separate from the system when it is clear that it is not working for the individual.

It is interesting, because 1 point appeals to greater systematization and standardization of care, and the second point leads to less. Yet they are both valid. Instead, I would suggest an improved systematized initial approach coupled with the flexibility to explore alternatives when the initial approach is not working.

While I recognize that the gist of your biological dilemma is unfortunate, and that it would be ideal to have a more solid biological basis for our diagnoses and treatments, this is merely a statement of the limitation of our scientific evidence which is likely to endure for quite a long time, perhaps forever. It does not, however, invalidate the field. Our treatments are proven to be efficacious, and we need not know why they are efficacious in order to utilize them. After all, if an old-fashioned TV is fuzzy, do you not bang on it until the picture clears?

What may be conflicting you is the limitations on efficacy and the risks with the treatment. I make no apologies for this. It is the state of things. All psychiatrists want better and safer drugs. We must weigh the benefits and risks of our treatment vs. the projected outcomes of not treating. This is where so many fail to recognize the need for what we do. It is not so important because our interventions are so successful and without risk -- it is instead because not treating serious mental illness is so often disastrous.

Hi, thanks for your sound and lucid arguments. I agree with a lot of what you say, and I admit that many things I have said in this thread were immature or incorrect. I think my assumptions about malpractice were incorrect. Another poster made a point that seeing your dermatologist can lead to demons. Re-reading the posts, I see that it was splik who said that. I owe him my thanks as well.

I'm glad you share my views on chemical imbalances. To me it's rational to say that it can be either cause or effect, maybe sometimes one and maybe sometimes the other. But you point out that this is clear to psychiatrists as well. Perhaps my assumption is outdated. Maybe psychiatrists thought this way ten or twenty years ago, but no longer explain etiology by chemical imbalances. I wonder what percentage of psychiatrists still think this way, if we were to make an educated guess.

 

[chiron89]

What you're giving here isn't feedback. Feedback usually refers to a person's specific actions and performance, whereas you're sharing a perception of an entire profession (two of them, actually). That perception seems to be shaped by incomplete or incorrect information. It's hard to engage with many of your concerns since they are predicated on ideas that not many of us actually share (eg, I'm not seeing anyone here standing up for the cause of biological reductionism).

Good points. I'll do my best to honestly answer by sharing as much as I feel comfortable. I'm actually going to sleep right now, but I'll finish this post tomorrow. Short answer: I have a chip on my shoulder.

 

[Roy3333]

The best way to kill a troll is to stop feeding them....

 

[birchswing]

This forum has low specificity and high sensitivity for troll.

 

[sunlioness]

Hi, thanks for your sound and lucid arguments. I agree with a lot of what you say, and I admit that many things I have said in this thread were immature or incorrect. I think my assumptions about malpractice were incorrect. Another poster made a point that seeing your dermatologist can lead to demons. Re-reading the posts, I see that it was splik who said that. I owe him my thanks as well.

I'm glad you share my views on chemical imbalances. To me it's rational to say that it can be either cause or effect, maybe sometimes one and maybe sometimes the other. But you point out that this is clear to psychiatrists as well. Perhaps my assumption is outdated. Maybe psychiatrists thought this way ten or twenty years ago, but no longer explain etiology by chemical imbalances. I wonder what percentage of psychiatrists still think this way, if we were to make an educated guess.

This is anecdotal, but in my career I've only met one psychiatrist who spoke in terms of chemical imbalances. That was my first boss out of residency who owned a private practice. This was in 2008 or 2009. Her office was next to mine and she often kept her door open so I could hear how she talked to patients. So I called her on it. She said she knew it was BS, but it helped patients to understand and normalize their illness. I disagreed. And I still do.

But the point is, even she didn't think that way. She just talked that way because it was easier. That was actually the least of her issues. I wasn't there very long.

 

[chiron89]

The best way to kill a troll is to stop feeding them....

You can say what you want about this thread, but I would argue that there's value. Even if I do come across poorly at times, I'm helping myself and maybe others clarify some important points.

 

[chiron89]

What you're giving here isn't feedback. Feedback usually refers to a person's specific actions and performance, whereas you're sharing a perception of an entire profession (two of them, actually). That perception seems to be shaped by incomplete or incorrect information. It's hard to engage with many of your concerns since they are predicated on ideas that not many of us actually share (eg, I'm not seeing anyone here standing up for the cause of biological reductionism).

Hi again. I just woke up feeling refreshed and I'd like to field your response. First of all, I'm sorry to everyone for being combative. I think I may have either interpreted (or misinterpreted) some responses as having a sour tone, and this could have soured my tone. Secondly, it's evident to me now that I had many incorrect assumptions. I wasn't well informed on the issue of malpractice (which I learned actually is relevant to the field) and I also assumed that more people than not explained etiology by chemical imbalances.

I did admit that I have a chip on my shoulder. I'll explain. There were two years in my young adult life when I took medications. Each of these years, my grade point average dropped from mostly A's and a few B's to getting C's, D's, and F's. My friendships waned, and I became reckless and impulsive. I had a really bad response to these medications. When I stopped them, not on my psychiatrist's advice but on my own common sense, my grade point average went back up again, and my most important friendships were mended.

I actually spoke to two or three qualified psychiatrists about the medications I was given. They didn't have much to say about my second experience, but regarding my first experience, they both said the psychiatrist was incompetent and that she prescribed a toxic combination. I am not the type of person who would ever file a malpractice suit, unless a surgeon were to steal my organs and sell them on the black market—in other words, I'm a gentle soul. I will point out that the first experience was ten years ago, and the second was six or seven. The field has evolved since then, and there's a lot of new information.

 

[Ceke2002]

This is anecdotal, but in my career I've only met one psychiatrist who spoke in terms of chemical imbalances. That was my first boss out of residency who owned a private practice. This was in 2008 or 2009. Her office was next to mine and she often kept her door open so I could hear how she talked to patients. So I called her on it. She said she knew it was BS, but it helped patients to understand and normalize their illness. I disagreed. And I still do.

But the point is, even she didn't think that way. She just talked that way because it was easier. That was actually the least of her issues. I wasn't there very long.

Anecdotal here as well, but in 20+ years I've never heard a Psychiatrist use the words 'chemical imbalance'. I've always thought of it more as a term the media uses because it's easier for people to conceptualise.

 

[chiron89]

I think some posters have alluded to this, but my experience made me think about ways psychiatrists can measure progress. I came up with two ways actually, which apply fairly well to students. The first is a scale of academic success. Have their grades gone up or down since starting these medications? Is there a noticeable change? The second is social adjustment. Have relationships with family and friends suffered since starting treatment? Have they lost old friends, made new friends, strengthened bonds or weakened them? I think both of these measurements are easy to track. Admittedly, they don't create a perfect picture. Maybe someone's grades go down because they gain interest in a different major. But at least they serve as noticeable red flags, which can be judged at the discretion of the psychiatrist.

 

[sunlioness]

I'm sorry that happened to you, Chiron. There are some really bad ones out there. My first boss among them. And not because she talked about chemical imbalances. (She also proudly declared that she was the "Benzo Queen" and . . . Well, lots of stuff I hesitate to even put in writing. I still have guilt that I didn't report her. But I was advised by the attorney I consulted that if I did so, she would likely report me in retaliation and even if proven baseless, I would easily spend over $10K I didn't have at that point in my career fighting it and have to explain it to licensing boards and on credentialing applications for the rest of my life. ) Fortunately, it's my understanding that she no longer practices.

But, enough of that.

Here was my spiel back when I had more than 15 minutes per patient and saw fewer than 15 people per day.

"We don't really entirely know what causes depression. There are a lot of theories around it, but in the end it's probably some combination of genetic predisposition and environment. There's no evidence to support the idea that you're deficient in any one chemical. The science just isn't there yet. We're not even entirely sure how our meds work. We know what they do. They increase the available serotonin. But we don't know that this is why they work. But we do know that they do work for a lot of people and that they are generally safe. You may experience the following side effects . . . Etc. Please don't hesitate to call if you experience anything you have a question about even if you're not sure it's related."

 

[chiron89]

I'm sorry that happened to you, Chiron. There are some really bad ones out there. My first boss among them. And not because she talked about chemical imbalances. (She also proudly declared that she was the "Benzo Queen" and . . . Well, lots of stuff I hesitate to even put in writing. I still have guilt that I didn't report her. But I was advised by the attorney I consulted that if I did so, she would likely report me in retaliation and even if proven baseless, I would spend over $10K fighting it and have to explain it to licensing boards and credentialing applications for the rest of my life. ) Fortunately, it's my understanding that she no longer practices.

But, enough of that.

Here was my spiel back when I had more than 15 minutes per patient and saw fewer than 15 people per day.

"We don't really entirely know what causes depression. There are a lot of theories around it, but in the end it's probably some combination of genetic predisposition and environment. There's no evidence to support the idea that you're deficient in any one chemical. The science just isn't there yet. We're not even entirely sure how our meds work. We know what they do. They increase the available serotonin. But we don't know that this is why they work. But we do know that they do work for a lot of people and that they are generally safe. You may experience the following side effects . . . Etc."

I like that spiel. The idea that there's a genetic component makes a lot of sense to me. I personally believe this idea. I agree with the view that it's a combination of genetics and environment. It's interesting to think that a symptom caused by genetics might become a strength after therapy or self-growth. Like depression and creativity. Or anxiety and sensitivity. If Howard Hughes had received good therapy, maybe he could have done more for aviation. Same with David Foster Wallace and writing. It does seem that a lot of our emotions are two-sided coins.

Your former boss does sound unpleasant. I appreciate you sharing that story.

 

[MLT2MT2DO]

This forum has low specificity and high sensitivity for troll.

I think our specificity is actually pretty good. Then again I'm a a doctor who is more interested in misdiagnosing someone than practicing humility, so what do I know.

Sent from my SM-G900V using SDN mobile

 

[birchswing]

Anecdotal here as well, but in 20+ years I've never heard a Psychiatrist use the words 'chemical imbalance'. I've always thought of it more as a term the media uses because it's easier for people to conceptualise.

It could be that in Australia you haven't seen as many pharmaceutical advertisements. In the US, I think it was all the TV commercials that helped popularize the chemical imbalance theory.

When you see ads like the following on TV (that are legally vetted by the FDA), it's not hard to see why so many people believe/talk about chemical imbalances:



And the name of SSRIs themselves made people feel an ownership of their understanding of what the medication is doing. They're told that they don't have enough serotonin, and the name of the medication describes it as preventing reuptake of serotonin. It would be like if you were told headaches were caused by quarks and the headache medicine had a very scientific sounding anti-quark mechanism. I randomly picked quark because I couldn't think of another sciency sounding random cause for headaches; I know they're subatomic particles.

Edit: Even the tagline of the commercial, "When you know more about what's wrong, you can help make it right" is a clear callback to the Chemical Imbalance animation earlier in the commercial. In short, I think all this was done very purposefully. Not just to make it easier for patients to understand, as it completely ignores all known contributing factors to depression in the biopsychosocial model and only focuses on one unproven biological contributor.

 

[smalltownpsych]

Hi again. I just woke up feeling refreshed and I'd like to field your response. First of all, I'm sorry to everyone for being combative. I think I may have either interpreted (or misinterpreted) some responses as having a sour tone, and this could have soured my tone. Secondly, it's evident to me now that I had many incorrect assumptions. I wasn't well informed on the issue of malpractice (which I learned actually is relevant to the field) and I also assumed that more people than not explained etiology by chemical imbalances.

I did admit that I have a chip on my shoulder. I'll explain. There were two years in my young adult life when I took medications. Each of these years, my grade point average dropped from mostly A's and a few B's to getting C's, D's, and F's. My friendships waned, and I became reckless and impulsive. I had a really bad response to these medications. When I stopped them, not on my psychiatrist's advice but on my own common sense, my grade point average went back up again, and my most important friendships were mended.

I actually spoke to two or three qualified psychiatrists about the medications I was given. They didn't have much to say about my second experience, but regarding my first experience, they both said the psychiatrist was incompetent and that she prescribed a toxic combination. I am not the type of person who would ever file a malpractice suit, unless a surgeon were to steal my organs and sell them on the black market—in other words, I'm a gentle soul. I will point out that the first experience was ten years ago, and the second was six or seven. The field has evolved since then, and there's a lot of new information.

Psychotropic medications effect people in many different ways and their are risks associated with taking them. Patients can experience a wide variety of positive and negative effects. Some people do respond well to anti-depressant medications, but it is impossible to identify who those people are without trying the medication. This should be explained better by the person prescribing the medication. Even with a medication like opiates there is a variable response. I take an opiate and experience the intended pain relief and also an incredibly effective relief of psychological tension or stress. I also experience minimal or no negative side effects such as nausea or constipation (in other words, a strong biological predisposition for addiction to opiates). Meanwhile, my daughter took a couple of vicodin after a tonsillectomy and vomited due to the overwhelming nausea. Her response was, "how could people get addicted to this stuff?"

 

[hamstergang]

And the name of SSRIs themselves made people feel an ownership of their understanding of what the medication is doing. They're told that they don't have enough serotonin, and the name of the medication describes it as preventing reuptake of serotonin.

I agree with your post except this part. They're called SSRIs because that's what they do. Grouping medications under their mechanism of action is actually quite standard and useful. Grouping meds by titles like antidepressant is less useful as it groups dissimilar meds and ignores other disorders that they treat.

 

[birchswing]

I agree with your post except this part. They're called SSRIs because that's what they do. Grouping medications under their mechanism of action is actually quite standard and useful. Grouping meds by titles like antidepressant is less useful as it groups dissimilar meds and ignores other disorders that they treat.

I can see that. But my understanding is that this particular mechanism is not the one that actually treats the symptoms of anxiety and depression? It's the mechanism that was being marketed. But aren't there other mechanisms the drug has that are unknown that may be more responsible for its treatment effects?

 

[thoffen]

I can see that. But my understanding is that this particular mechanism is not the one that actually treats the symptoms of anxiety and depression? It's the mechanism that was being marketed. But aren't there other mechanisms the drug has that are unknown that may be more responsible for its treatment effects?

All antidepressants lead to increased serotonin or norepinephrine or both in the synapse. It is the mechanism of action of the drugs, not something unknown.

Doesn't mean depression = serotonin deficient.

 

[Ceke2002]

It could be that in Australia you haven't seen as many pharmaceutical advertisements. In the US, I think it was all the TV commercials that helped popularize the chemical imbalance theory.

When you see ads like the following on TV (that are legally vetted by the FDA), it's not hard to see why so many people believe/talk about chemical imbalances:



And the name of SSRIs themselves made people feel an ownership of their understanding of what the medication is doing. They're told that they don't have enough serotonin, and the name of the medication describes it as preventing reuptake of serotonin. It would be like if you were told headaches were caused by quarks and the headache medicine had a very scientific sounding anti-quark mechanism. I randomly picked quark because I couldn't think of another sciency sounding random cause for headaches; I know they're subatomic particles.

Edit: Even the tagline of the commercial, "When you know more about what's wrong, you can help make it right" is a clear callback to the Chemical Imbalance animation earlier in the commercial. In short, I think all this was done very purposefully. Not just to make it easier for patients to understand, as it completely ignores all known contributing factors to depression in the biopsychosocial model and only focuses on one unproven biological contributor.

But that's still not a Psychiatrist saying it to a patient, I mean an FDA approval commercial isn't the same thing as a statement from a treating Physician. So even if I had seen more ads like that on Australian TV I still would have placed it under the category of 'media' not 'Psychiatry'. And even if the adverts had hired some random Psychiatrist to be their talking head, I still don't think you could then take that to be an implicit understanding that 'All of Psychiatry reduces the understanding of X down to Y'.

 

[Ceke2002]

Psychotropic medications effect people in many different ways and their are risks associated with taking them. Patients can experience a wide variety of positive and negative effects. Some people do respond well to anti-depressant medications, but it is impossible to identify who those people are without trying the medication. This should be explained better by the person prescribing the medication. Even with a medication like opiates there is a variable response. I take an opiate and experience the intended pain relief and also an incredibly effective relief of psychological tension or stress. I also experience minimal or no negative side effects such as nausea or constipation (in other words, a strong biological predisposition for addiction to opiates). Meanwhile, my daughter took a couple of vicodin after a tonsillectomy and vomited due to the overwhelming nausea. Her response was, "how could people get addicted to this stuff?"

Oddly enough I still managed to get addicted to opiates despite getting negative side effects. It took at least 18 months of daily use for those side effect to eventually start to die down, but before that every time I shot Heroin I would vomit almost non stop, to the point that even other addicts were outright questioning why I would bother putting myself through that.

 

[Ceke2002]

Hi again. I just woke up feeling refreshed and I'd like to field your response. First of all, I'm sorry to everyone for being combative. I think I may have either interpreted (or misinterpreted) some responses as having a sour tone, and this could have soured my tone. Secondly, it's evident to me now that I had many incorrect assumptions. I wasn't well informed on the issue of malpractice (which I learned actually is relevant to the field) and I also assumed that more people than not explained etiology by chemical imbalances.

I did admit that I have a chip on my shoulder. I'll explain. There were two years in my young adult life when I took medications. Each of these years, my grade point average dropped from mostly A's and a few B's to getting C's, D's, and F's. My friendships waned, and I became reckless and impulsive. I had a really bad response to these medications. When I stopped them, not on my psychiatrist's advice but on my own common sense, my grade point average went back up again, and my most important friendships were mended.

I actually spoke to two or three qualified psychiatrists about the medications I was given. They didn't have much to say about my second experience, but regarding my first experience, they both said the psychiatrist was incompetent and that she prescribed a toxic combination. I am not the type of person who would ever file a malpractice suit, unless a surgeon were to steal my organs and sell them on the black market—in other words, I'm a gentle soul. I will point out that the first experience was ten years ago, and the second was six or seven. The field has evolved since then, and there's a lot of new information.

I'm really sorry to hear of your experiences, Chiron.

There are some really bad apples out there that can spoil it for the whole bunch, but I hope through reading some of the posts from the Psychiatrists on here that you're able to see that not all Psychiatrists equate to the negativity of the field that you've been exposed to.

I can relate to how you feel though, although in my case it wasn't an issue of medications being wrongly prescribed that lead me to have such an ingrained mistrust of Psychiatrists (male Psychiatrists specifically) for a good many years. I've mentioned this a number of times before when discussions of bad psychiatry have arisen previously, but a Psychiatrist I was seeing back in the late 90s spent close to a year psychologically manipulating and grooming myself and many of his other female patients, before gradually sexualising therapy with a view to eventually starting a full blown sexual relationship with us (other patients he just outright molested and raped while he had them under sedation). He also got off on placing patients in what he considered to be controlled states of pain and/or discomfort under the guise of breaking down therapeutic resistance, and by 'got off on' I mean there was absolutely no legitimate therapeutic benefit to what he was doing, he just really enjoyed watching his patients suffer (the expression I'd use to describe his response would probably be something like 'glee').

I was a lot luckier than some, in that I did eventually manage to break free of the mental hold he had over me before things progressed beyond a certain point in terms of sexual exploitation/abuse, but even so my experiences with him had a major long term impact on my ability to trust, or engage with an entire gender segment of the Psychiatric community (the Psychiatrist I'm seeing now was the first male Psychiatrist I'd even agreed to see in more than 15 years at the outset, and it took another couple of years after that before I managed to build any sort of real trust with him).

It's good that you're able to talk about your own negative experiences, and to get a countering viewpoint, because if there's one thing I've learnt over the years (both from working with my own Psychiatrist, and from the folks on here -- the majority of whom I think are bl00dy amazing!) it's that those few bad apples are the exception and not the rule.

 

[birchswing]

All antidepressants lead to increased serotonin or norepinephrine or both in the synapse. It is the mechanism of action of the drugs, not something unknown.

Doesn't mean depression = serotonin deficient.

I didn't mean that the serotonin mechanism is unknown, and I don't think I said that. What I believe I've read in this forum, though, is that the increased serotonin is not what treats the depression and that there are other mechanisms of SSRIs, to this point unknown, that may lead to the treatment effects. I believe someone here said that if it were the serotonin that had treatment effects, it would take effect nearly immediately rather than 2-4 weeks. And my original point was that the name of the drug is the same as the specific mechanism shown in advertisements That's like having a commercial that says your computer is slow because of viruses, so buy this product called anti-virus. It increases the sense of ownership of understanding. One sales technique is to increase consumers' perception that they have figured something out—that they own a solution. That was the point I was making in connecting the name of the drug and the mechanism shown in the advertisements.

 

[chiron89]

I'm really sorry to hear of your experiences, Chiron.

There are some really bad apples out there that can spoil it for the whole bunch, but I hope through reading some of the posts from the Psychiatrists on here that you're able to see that not all Psychiatrists equate to the negativity of the field that you've been exposed to.

I can relate to how you feel though, although in my case it wasn't an issue of medications being wrongly prescribed that lead me to have such an ingrained mistrust of Psychiatrists (male Psychiatrists specifically) for a good many years. I've mentioned this a number of times before when discussions of bad psychiatry have arisen previously, but a Psychiatrist I was seeing back in the late 90s spent close to a year psychologically manipulating and grooming myself and many of his other female patients, before gradually sexualising therapy with a view to eventually starting a full blown sexual relationship with us (other patients he just outright molested and raped while he had them under sedation). He also got off on placing patients in what he considered to be controlled states of pain and/or discomfort under the guise of breaking down therapeutic resistance, and by 'got off on' I mean there was absolutely no legitimate therapeutic benefit to what he was doing, he just really enjoyed watching his patients suffer (the expression I'd use to describe his response would probably be something like 'glee').

I was a lot luckier than some, in that I did eventually manage to break free of the mental hold he had over me before things progressed beyond a certain point in terms of sexual exploitation/abuse, but even so my experiences with him had a major long term impact on my ability to trust, or engage with an entire gender segment of the Psychiatric community (the Psychiatrist I'm seeing now was the first male Psychiatrist I'd even agreed to see in more than 15 years at the outset, and it took another couple of years after that before I managed to build any sort of real trust with him).

It's good that you're able to talk about your own negative experiences, and to get a countering viewpoint, because if there's one thing I've learnt over the years (both from working with my own Psychiatrist, and from the folks on here -- the majority of whom I think are bl00dy amazing!) it's that those few bad apples are the exception and not the rule.

Thanks for sharing. Like you, I think it's really important to talk about bad experiences.

 

[chiron89]

I didn't mean that the serotonin mechanism is unknown, and I don't think I said that. What I believe I've read in this forum, though, is that the increased serotonin is not what treats the depression and that there are other mechanisms of SSRIs, to this point unknown, that may lead to the treatment effects. I believe someone here said that if it were the serotonin that had treatment effects, it would take effect nearly immediately rather than 2-4 weeks. And my original point was that the name of the drug is the same as the specific mechanism shown in advertisements That's like having a commercial that says your computer is slow because of viruses, so buy this product called anti-virus. It increases the sense of ownership of understanding. One sales technique is to increase consumers' perception that they have figured something out—that they own a solution. That was the point I was making in connecting the name of the drug and the mechanism shown in the advertisements.

I think I see what you're saying. But your analogy about computer viruses seems a little off. Antidepressants are to depression what antivirus software is to computer viruses. But the name SSRI doesn't follow this logic. The name SSRI came about with a consideration for the mechanism of the pill. The names antidepressant and antivirus software most likely came about with advertising considerations, and became embedded in popular culture.

 

[birchswing]

I think I see what you're saying. But your analogy about computer viruses seems a little off. Antidepressants are to depression what antivirus software is to computer viruses. But the name SSRI doesn't follow this logic. The name SSRI came about with a consideration for the mechanism of the pill. The names antidepressant and antivirus software most likely came about with advertising considerations, and became embedded in popular culture.

That's a good point. But while serotonin reuptake is one mechanism of SSRIs, as far as I know, it isn't the mechanism by which they have have treatment effect. It is the mechanism, though, that the public was being told they worked by. The public was sold a narrative. "Your computer has viruses which is why it's slow and this anti-virus product will get rid of them" is a good narrative and possibly true. "Your brain doesn't have enough serotonin and this serotonin reuptake-blocking product will fix that" is also a good narrative. That was my point. It was a good name to fit the narrative.

 

[thoffen]

That's a good point. But while serotonin reuptake is one mechanism of SSRIs, as far as I know, it isn't the mechanism by which they have have treatment effect. It is the mechanism, though, that the public was being told they worked by. The public was sold a narrative. "Your computer has viruses which is why it's slow and this anti-virus product will get rid of them" is a good narrative and possibly true. "Your brain doesn't have enough serotonin and this serotonin reuptake-blocking product will fix that" is also a good narrative. That was my point. It was a good name to fit the narrative.

Sorry, but you're wrong. Increasing serotonin (and/or norepinephrine) is the mechanism of action of the drug that leads to therapeutic benefit for depression, and is also the mechanism for every single FDA-approved drug for monotherapy of unipolar depression. They don't work by some unknown mechanism and incidentally increase serotonin.

Still, it doesn't mean that "Your brain doesn't have enough serotonin and this serotonin reuptake-blocking product will fix that" is a good narrative.

Just like if you give a calcium channel blocker for hypertension, it doesn't mean that "Your blood vessels have too much calcium and this calcium-channel-blocking product will fix that" is a good narrative. But blocking calcium channels is the way these drugs work for hypertension.

 

[birchswing]

Sorry, but you're wrong. Increasing serotonin (and/or norepinephrine) is the mechanism of action of the drug that leads to therapeutic benefit for depression, and is also the mechanism for every single FDA-approved drug for monotherapy of unipolar depression. They don't work by some unknown mechanism and incidentally increase serotonin.

Still, it doesn't mean that "Your brain doesn't have enough serotonin and this serotonin reuptake-blocking product will fix that" is a good narrative.

Just like if you give a calcium channel blocker for hypertension, it doesn't mean that "Your blood vessels have too much calcium and this calcium-channel-blocking product will fix that" is a good narrative. But blocking calcium channels is the way these drugs work for hypertension.

Sorry. I was basing this off of something I thought I had read on this forum. I've been here for years so I'm not sure where to find it but I'll do some looking around to see what I thought I had read.

EDIT: I thought searching a psychiatry forum for old posts about SSRIs would take forever. Google came through for me.

It was actually from a thread I started!
http://forums.studentdoctor.net/thr...otonin-not-being-cause-of-depression.1095706/


In response to me, @notdeadyet wrote:

We've known for a long time that serotonin levels do not correspond to depression. If it did, then SSRIs (which work very quickly) would show very rapid improvement to depression, instead of four or even six weeks. The theory is that there's a downstream effect that is occurring that is much slower and we don't know what that effect is.

Bad doctors have sort of kept the misunderstanding going by misrepresenting how SSRIs work.

http://forums.studentdoctor.net/thr...otonin-not-being-cause-of-depression.1095706/

 

[birchswing]

While I was searching found another post making the same point:

First of all, i'm not learning that stuff in "grad school", i have a personal interest in the subject-matter, thats all. Well, the majority of research says that "lower serotonin levels" must be false, because if the "serotonin levels" were low, then the SSRIs-or whatever- would directly correct "the imbalance" and bring instant relief. As far as we know thats not the case and it takes several days/weeks until the effect starts to take place, possibly meaning that there must be some gradual cellular/receptor change taking place. Then there are drugs such as the SSREs that also bring relief but work in the opposite way-lowering serotonin levels in the synapse. How would you respond to these criticisms?


As far as i know, the "serotonin-level" hypothesis is dead, but the hypothesis still lives in various "serotonin-receptor" models with various proposals of increased/dicreased number of 5-HT receptors, increased/decreased sensitivity, up- or down-regulation of pre-synaptic auto-receptors etc. (also the BDNF hypothesis that you state, which could be a common pathway or a finding completely unrelated to mood regulation). Well, i guess that if you search hard enough you will eventually find some decreased serotonin levels-whatever that means. There would probably be some "depressed sub-populations" showing some correlation, but this is still very weak scientifically speaking. I could find hundreds more of pro- and con- correlational studies like the ones you post. Furthermore, the purely biological proposals are hugely inadequate IMO, since they say nothing about the neuroscientific/neuropsychological mechanisms per se. E.g. does the serotonin receptor activity correlates with mood state, mood intensity, mood experience, mood excitation/inhibition, mood what? What is the role of the serotonergic system in normal mood and emotional experience? You would need to explicitly state these issues if you want a valid biological test showing correlations between a chemical level and a psychological level (e.g. x level of serotonin reveals y level of change in that aspect of mood experience/intensity/level). This would be truly valid. But maybe i ask for too much.

 

[hamstergang]

Sorry. I was basing this off of something I thought I had read on this forum.

What those quotes are saying is that the increase in serotonin doesn't directly proxide the antidepressant effect. Instead, the increased serotonin leads to other changes in the brain that are ultimately responsible.