I find it so frustrating that people cannot keep more than 1 idea in their head at the same time. It's obvious from data, clinical experience and anecdote that the same drug can be a poison, a panacea or a placebo, depending on who takes it and in what circumstances. People are hugely varied, brains are hugely varied, societies are hugely varied: why would everyone be affected by a drug in the same way, leaving out for a minute facts like tolerance and dosages. If we just understood this, we would stop having the hype cycles of "prozac makes you better than well" "prozac makes you suicidal" and "prozac is placebo." It can be any of those depending on as the psychedelic folks say, set and setting.
I read as a patient whose life was probably saved by an SSRI , a (often reluctant) prescriber, and someone who had an awful time tapering off the same SSRI and was never warned this could be a possibility. It’s hard to hold all these varying truths at the same time, but, I try. So. Very nicely said!
In 2009 during my intern year, at a talk drug rep responded to a question, “That would not be the right patient for this drug.”
In a room of forty residents, I corrected him and said “You mean it would not be the right drug for that patient. There might not be any patients for this drug.”
As an older colleague and a friend, I’m very sorry to hear that you are writing “out of a sense of exhaustion.” I am not replying here to minimize or “cheer-lead” you out of your felt experience; namely, “exhaustion at confronting the flood of human suffering with the flawed instruments” of treatment we possess in our beleaguered profession. The suffering is real; and alas, the limitations of our treatments are also real.
Rather, I write in the hope that we can enlarge the discussion with some historical perspective and some personal observations, based on my almost 45 years in psychiatry. To be clear: professional longevity should never be confused with wisdom (as I know my critics would agree!), but it does confer an abundance of experiences.
Having trained in the late 70s and early 80s, I have seen our profession go through many cycles of hope, dashed hope, confusion, recovery, pessimism and pride. I am also aware that the “exhaustion” you describe is a professional hazard, not only in psychiatry, but in many medical specialties. Sadly, the latest national survey finds that over 45% of physicians report at least one symptom of “burnout.” [1] I trust you have not reached that stage, but “exhaustion” is bad enough!
Since you have focused on psychiatric medication, Awais, I will follow your lead and offer a few observations. I can recall a time in the early 1980s, when psychiatrists on an inpatient unit often used the phrase, “the Haldol shuffle.” They—we—were of course describing the terrible side effect of akathisia, which afflicted so many of our patients with schizophrenia maintained on “neuroleptics”—literally, “that which seizes the neuron” (lêpsis, meaning "a grasping" or "seizure”). Our present-day antipsychotic medications are a far cry from ideal, and still have many possible side effects--but akathisia is much less frequent with several of the newer “atypical” antipsychotics (e.g., 57% frequency with haloperidol, vs. about 3.5% with olanzapine and quetiapine) [2]
About eight years after I left residency, I ran one of the earliest (ca. 1990) clozapine clinics in Massachusetts. Many psychiatrists of a certain age will speak of clozapine as a “near-miracle” drug—this, despite its (overstated) hematological risks and (overly stringent) need for frequent monitoring. Awais, if you have not yet had the experience of watching a wracked and ruined life reintegrate, and even thrive, once treated with clozapine, you have not yet felt the salvific power of a psychiatric treatment! I described one such clozapine-treated patient—“Harry”—in an essay for the New York Times. I wrote, "Harry was one of the lucky ones. After a lifetime of schizophreni[c] hallucinations, hospitalizations, and all the attendant miseries, he was a genuinely new man.” [3]
I take heart, Awais, in your observation that “Even the much-doubted and much-maligned SSRIs, when they work, they work beautifully. With the right patient, you can see mania and psychosis melt away with mood stabilizers and antipsychotics. It’s a joy to see patients get better with treatment. I scoff at the skepticism of willfully ignorant critics who think we have made no advances in mental health treatment over the past century.”
Just so! Indeed, there have been significant treatment advances in the past 40 years—from TMS to esketamine to neuroactive steroids like brexanolone. Meanwhile, lithium “…remains the single most effective psychotropic agent in all of psychiatry”, yet often goes unheralded and under-utilized [4] Let’s also keep in mind that the performance of psychiatric medications sits squarely in the same modest-to-moderate range as many standard treatments in general medicine. [5] No, that’s certainly nothing to brag about, but it is worth remembering.
Finally, Awais, many of the frustrations and limitations you rightly attribute to somatic psychiatric treatments are not uncommon in several other medical specialties, such as oncology, rheumatology, and family practice. For example, that psychiatric medications can “both help and harm” is painfully true of drugs used in cancer treatment, where the side effects can sometimes be nearly as bad as the disease.
Yes, the benefits of some of our somatic treatments were overstated; and yes, their risks were often insufficiently communicated to our patients—most obviously, with the serotonergic antidepressants. But I have seen enough cases—in the hundreds, certainly—in which our medications helped turn a catastrophic illness into a remitted illness; and a shattered life into a life worth living. In short, Awais, do not despair—and for goodness sake, please take good care of yourself!
2. Juncal-Ruiz M, Ramirez-Bonilla M, Gomez-Arnau J, et al, Incidence and risk factors of acute akathisia in 493 individuals with first episode non-affective psychosis: a 6-week randomised study of antipsychotic treatment. Psychopharmacology (Berl). 2017 Sep;234(17):2563-2570
5. Leucht S, Hierl S, Kissling W, Dold M, Davis JM. Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses. Br J Psychiatry. 2012 Feb;200(2):97-106. doi: 10.1192/bjp.bp.111.096594. PMID: 22297588.].
I echo the exhaustion. It's not easy. For what it's worth your writing has helped me a lot in working through some of this mess whilst working as a psychiatrist: thank you, it's appreciated
Relevant update from my life: A few months ago, I shared that guanfacine had miraculously fixed my chronic catatonia symptoms after nearly 20 years of struggling with them. That effect faded with tolerance to the medication over the course of a few weeks, and I spent a while going on and off it because once the general tolerance had set in, the effects would be most helpful at the beginning, but over time being on a CNS depressant would wear me down.
THAT SAID, my catatonic symptoms are now in remission for the first time ever due to other psychological interventions (IFS therapy, attachment repair meditations, processing trauma both in meditations and actual conversations with therapists) and reading Patricia Crittenden's theory about how mental illness develops, developmentally and relationally. I've been off guanfacine for a couple weeks now and don't think I'll need to go back on or try other pharmaceuticals for catatonia in the future, since I think even if it recurs, I have the tools to find the inner conflicts or learned helplessness causing it and gently lead myself out.
I don't know if I can say for sure that the guanfacine was anything other than a detour, but I think it's quite possible that having a brief medication-caused remission opened me up to the possibility of recovery. So maybe failure isn't always failure?
I do think more clinicians should read Crittenden--she connects a lot of interdisciplinary ideas in a way that allows for rigorous research and precise hypothesis formation that I think has potential to tame a significant portion of what seems like chaos under the current mental health treatment paradigm. And even if not her theory, *something like it* should be the goal--something that can serve as a map for treatment and integrate psychoanalytic, neurobiological, relational, and contextual factors in the development and change of mental health symptoms. I think there will turn out to be some irreducible level of risk and failure in psychiatric treatment, but IMO we can get to the point where most of that is due to trauma-treatment-related decompensation, resistance produced by pyschological defenses, and the complexity of the brain with regard to psychopharmcalogical interventions, whereas right now a ton of it is just due to clinicians being unable to correctly see how and why the person in front of them is suffering.
Is it too silly or appreciated if I send you a "cyber hug"? I think I can to SOME extent understand how exhausting it must be to be a clinical psychiatrist and scholar trying to maintain a nuanced and complex perspective, because it's hard enough, sometimes, to do this as a scholar of philosophy with lived experience.
People do want it to be one or the other: Either ANTIPSYCHIATRY and SO-CALLED MEDS ARE POISON, and then people should either just get a grip on themselves or do a revolution to fix society (depending on whether the antipsychiatrist is politically right-wing or left-wing), or else it's TRUST YOUR DOCTOR and TAKE YOUR MEDS they will not harm you, only help you, and protect your brain from the disease that's otherwise gonna make it rot over time!
Then there's this other false dichotomy on the META level: Either we accept the above black-and-white-thinking, OR it's just total relativism and anything goes, it's all just opinions, maaan!
Dear Awais, I too used to despair at the state of psychiatry, but I realised that a lot of my despair was because I spent too much time online, either reading critical voices or reading about the messy evidence base. In the real world, good psychiatric care is genuinely amazing and often life-saving. Both patients and families value it. This is not to dismiss the uncertainty, our limited evidence base or the need for humility, but I hope you will feel more energised by the experience of providing good clinical care.
Love your post, and agree with every sentence. But it doesn't sound like you, Dr. A. I hear Valium provides reliable relief of psychic tension...
Seriously, step one is to embrace humility and uncertainty. Too often we rely, wittingly or unwittingly, on the placebo effect of a highly confident prescriber (or psychotherapist). Meanwhile we perform brain surgery with stone tools—because those are the best tools we have. It's a happy fact that many benefit from this immature science and our imperfect, flawed treatments. And a sad fact that many don't.
Psychiatry has come in for a bashing because it has not been transparent about the risks involved in taking psych meds. Whether this is because the drug companies never informed doctors of the risks or compensated them for looking the other way, I do not know. I also wonder why all of this handwringing and public acknowledgment of limitations is coming about now when it should have been front and center decades ago.
How we talk about our tools is perhaps more important that what we say about them, so the way Awais frames his "real message to the public" is a critical paragraph.
We are stuck with the public's (and our own) struggles to keep 2 apparently contradictory ideas in our heads, as if we're all one big mass of borderline thinking. Part of our job is to accept and anticipate that in our patients. That we have imperfect tools is not exactly unique to medicine, but cardiology and others have somehow seemed to evade the trap of " if it's imperfect, then it's a crap shoot" that we sometimes hear. There's no shame in imperfection, and analogizing our imperfections to those of cardiologist (among others) can be a useful approach to the rejoinder of " you really don't know what you're doing, do you?" There's a wide spectrum from perfect tools to useless ones.
Awais, I'm sorry to see the frustration bubble over like that but its totally understandable. I almost just wrote "I hope you can get some perspective", but that's wrong because your perspective is dead on. It's just that living with problems seen so clearly can be difficult. Maybe you can take some inspiration from some of your successful patients -- perhaps some of them have found ways to live well in our frustratingly imperfect world. I imagine that you've helped them to do so.
Your post has motivated me to (try to) finish one of my own on the problems that you raise as they are manifested in the history of documentaries about schizophrenia. Just...watching all of that pain can be trying.
I find it so frustrating that people cannot keep more than 1 idea in their head at the same time. It's obvious from data, clinical experience and anecdote that the same drug can be a poison, a panacea or a placebo, depending on who takes it and in what circumstances. People are hugely varied, brains are hugely varied, societies are hugely varied: why would everyone be affected by a drug in the same way, leaving out for a minute facts like tolerance and dosages. If we just understood this, we would stop having the hype cycles of "prozac makes you better than well" "prozac makes you suicidal" and "prozac is placebo." It can be any of those depending on as the psychedelic folks say, set and setting.
I read as a patient whose life was probably saved by an SSRI , a (often reluctant) prescriber, and someone who had an awful time tapering off the same SSRI and was never warned this could be a possibility. It’s hard to hold all these varying truths at the same time, but, I try. So. Very nicely said!
In 2009 during my intern year, at a talk drug rep responded to a question, “That would not be the right patient for this drug.”
In a room of forty residents, I corrected him and said “You mean it would not be the right drug for that patient. There might not be any patients for this drug.”
He conceded my point.
Dear Awais,
As an older colleague and a friend, I’m very sorry to hear that you are writing “out of a sense of exhaustion.” I am not replying here to minimize or “cheer-lead” you out of your felt experience; namely, “exhaustion at confronting the flood of human suffering with the flawed instruments” of treatment we possess in our beleaguered profession. The suffering is real; and alas, the limitations of our treatments are also real.
Rather, I write in the hope that we can enlarge the discussion with some historical perspective and some personal observations, based on my almost 45 years in psychiatry. To be clear: professional longevity should never be confused with wisdom (as I know my critics would agree!), but it does confer an abundance of experiences.
Having trained in the late 70s and early 80s, I have seen our profession go through many cycles of hope, dashed hope, confusion, recovery, pessimism and pride. I am also aware that the “exhaustion” you describe is a professional hazard, not only in psychiatry, but in many medical specialties. Sadly, the latest national survey finds that over 45% of physicians report at least one symptom of “burnout.” [1] I trust you have not reached that stage, but “exhaustion” is bad enough!
Since you have focused on psychiatric medication, Awais, I will follow your lead and offer a few observations. I can recall a time in the early 1980s, when psychiatrists on an inpatient unit often used the phrase, “the Haldol shuffle.” They—we—were of course describing the terrible side effect of akathisia, which afflicted so many of our patients with schizophrenia maintained on “neuroleptics”—literally, “that which seizes the neuron” (lêpsis, meaning "a grasping" or "seizure”). Our present-day antipsychotic medications are a far cry from ideal, and still have many possible side effects--but akathisia is much less frequent with several of the newer “atypical” antipsychotics (e.g., 57% frequency with haloperidol, vs. about 3.5% with olanzapine and quetiapine) [2]
About eight years after I left residency, I ran one of the earliest (ca. 1990) clozapine clinics in Massachusetts. Many psychiatrists of a certain age will speak of clozapine as a “near-miracle” drug—this, despite its (overstated) hematological risks and (overly stringent) need for frequent monitoring. Awais, if you have not yet had the experience of watching a wracked and ruined life reintegrate, and even thrive, once treated with clozapine, you have not yet felt the salvific power of a psychiatric treatment! I described one such clozapine-treated patient—“Harry”—in an essay for the New York Times. I wrote, "Harry was one of the lucky ones. After a lifetime of schizophreni[c] hallucinations, hospitalizations, and all the attendant miseries, he was a genuinely new man.” [3]
I take heart, Awais, in your observation that “Even the much-doubted and much-maligned SSRIs, when they work, they work beautifully. With the right patient, you can see mania and psychosis melt away with mood stabilizers and antipsychotics. It’s a joy to see patients get better with treatment. I scoff at the skepticism of willfully ignorant critics who think we have made no advances in mental health treatment over the past century.”
Just so! Indeed, there have been significant treatment advances in the past 40 years—from TMS to esketamine to neuroactive steroids like brexanolone. Meanwhile, lithium “…remains the single most effective psychotropic agent in all of psychiatry”, yet often goes unheralded and under-utilized [4] Let’s also keep in mind that the performance of psychiatric medications sits squarely in the same modest-to-moderate range as many standard treatments in general medicine. [5] No, that’s certainly nothing to brag about, but it is worth remembering.
Finally, Awais, many of the frustrations and limitations you rightly attribute to somatic psychiatric treatments are not uncommon in several other medical specialties, such as oncology, rheumatology, and family practice. For example, that psychiatric medications can “both help and harm” is painfully true of drugs used in cancer treatment, where the side effects can sometimes be nearly as bad as the disease.
Yes, the benefits of some of our somatic treatments were overstated; and yes, their risks were often insufficiently communicated to our patients—most obviously, with the serotonergic antidepressants. But I have seen enough cases—in the hundreds, certainly—in which our medications helped turn a catastrophic illness into a remitted illness; and a shattered life into a life worth living. In short, Awais, do not despair—and for goodness sake, please take good care of yourself!
Kind regards,
Ron
Ronald W. Pies, MD
1. https://www.ama-assn.org/practice-management/physician-health/what-physician-burnout
2. Juncal-Ruiz M, Ramirez-Bonilla M, Gomez-Arnau J, et al, Incidence and risk factors of acute akathisia in 493 individuals with first episode non-affective psychosis: a 6-week randomised study of antipsychotic treatment. Psychopharmacology (Berl). 2017 Sep;234(17):2563-2570
3. Ronald Pies, “A Guy, a Car: Beyond Schizophrenia,” New York Times, May 4, 2009. https://www.nytimes.com/2009/05/05/health/05case.html
4. Ruffalo ML, A Brief History of Lithium Treatment in Psychiatry. Primary Care Companion for CNS Disorders. Vol. 19, 2017.https://www.psychiatrist.com/pcc/history-of-lithium-treatment-in-psychiatry/
5. Leucht S, Hierl S, Kissling W, Dold M, Davis JM. Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses. Br J Psychiatry. 2012 Feb;200(2):97-106. doi: 10.1192/bjp.bp.111.096594. PMID: 22297588.].
I echo the exhaustion. It's not easy. For what it's worth your writing has helped me a lot in working through some of this mess whilst working as a psychiatrist: thank you, it's appreciated
Thank you for your honesty - and have a break!
I second both these sentiments.
Relevant update from my life: A few months ago, I shared that guanfacine had miraculously fixed my chronic catatonia symptoms after nearly 20 years of struggling with them. That effect faded with tolerance to the medication over the course of a few weeks, and I spent a while going on and off it because once the general tolerance had set in, the effects would be most helpful at the beginning, but over time being on a CNS depressant would wear me down.
THAT SAID, my catatonic symptoms are now in remission for the first time ever due to other psychological interventions (IFS therapy, attachment repair meditations, processing trauma both in meditations and actual conversations with therapists) and reading Patricia Crittenden's theory about how mental illness develops, developmentally and relationally. I've been off guanfacine for a couple weeks now and don't think I'll need to go back on or try other pharmaceuticals for catatonia in the future, since I think even if it recurs, I have the tools to find the inner conflicts or learned helplessness causing it and gently lead myself out.
I don't know if I can say for sure that the guanfacine was anything other than a detour, but I think it's quite possible that having a brief medication-caused remission opened me up to the possibility of recovery. So maybe failure isn't always failure?
I do think more clinicians should read Crittenden--she connects a lot of interdisciplinary ideas in a way that allows for rigorous research and precise hypothesis formation that I think has potential to tame a significant portion of what seems like chaos under the current mental health treatment paradigm. And even if not her theory, *something like it* should be the goal--something that can serve as a map for treatment and integrate psychoanalytic, neurobiological, relational, and contextual factors in the development and change of mental health symptoms. I think there will turn out to be some irreducible level of risk and failure in psychiatric treatment, but IMO we can get to the point where most of that is due to trauma-treatment-related decompensation, resistance produced by pyschological defenses, and the complexity of the brain with regard to psychopharmcalogical interventions, whereas right now a ton of it is just due to clinicians being unable to correctly see how and why the person in front of them is suffering.
Is it too silly or appreciated if I send you a "cyber hug"? I think I can to SOME extent understand how exhausting it must be to be a clinical psychiatrist and scholar trying to maintain a nuanced and complex perspective, because it's hard enough, sometimes, to do this as a scholar of philosophy with lived experience.
People do want it to be one or the other: Either ANTIPSYCHIATRY and SO-CALLED MEDS ARE POISON, and then people should either just get a grip on themselves or do a revolution to fix society (depending on whether the antipsychiatrist is politically right-wing or left-wing), or else it's TRUST YOUR DOCTOR and TAKE YOUR MEDS they will not harm you, only help you, and protect your brain from the disease that's otherwise gonna make it rot over time!
Then there's this other false dichotomy on the META level: Either we accept the above black-and-white-thinking, OR it's just total relativism and anything goes, it's all just opinions, maaan!
*cyberhug*
Dear Awais, I too used to despair at the state of psychiatry, but I realised that a lot of my despair was because I spent too much time online, either reading critical voices or reading about the messy evidence base. In the real world, good psychiatric care is genuinely amazing and often life-saving. Both patients and families value it. This is not to dismiss the uncertainty, our limited evidence base or the need for humility, but I hope you will feel more energised by the experience of providing good clinical care.
Love your post, and agree with every sentence. But it doesn't sound like you, Dr. A. I hear Valium provides reliable relief of psychic tension...
Seriously, step one is to embrace humility and uncertainty. Too often we rely, wittingly or unwittingly, on the placebo effect of a highly confident prescriber (or psychotherapist). Meanwhile we perform brain surgery with stone tools—because those are the best tools we have. It's a happy fact that many benefit from this immature science and our imperfect, flawed treatments. And a sad fact that many don't.
Psychiatry has come in for a bashing because it has not been transparent about the risks involved in taking psych meds. Whether this is because the drug companies never informed doctors of the risks or compensated them for looking the other way, I do not know. I also wonder why all of this handwringing and public acknowledgment of limitations is coming about now when it should have been front and center decades ago.
Is this actually true though? Do the majority of psychiatrists not warn about potential side effects and do regular blood tests etc. in your country?
Mine haven’t.
This is the support group I have joined for people who want to taper off psych meds: https://www.theinnercompass.org/
Sounds like you need a vacation and summer is over!
BTW, Citalopram has helped me avoid panic attacks for 15 years.
How we talk about our tools is perhaps more important that what we say about them, so the way Awais frames his "real message to the public" is a critical paragraph.
We are stuck with the public's (and our own) struggles to keep 2 apparently contradictory ideas in our heads, as if we're all one big mass of borderline thinking. Part of our job is to accept and anticipate that in our patients. That we have imperfect tools is not exactly unique to medicine, but cardiology and others have somehow seemed to evade the trap of " if it's imperfect, then it's a crap shoot" that we sometimes hear. There's no shame in imperfection, and analogizing our imperfections to those of cardiologist (among others) can be a useful approach to the rejoinder of " you really don't know what you're doing, do you?" There's a wide spectrum from perfect tools to useless ones.
Awais, I'm sorry to see the frustration bubble over like that but its totally understandable. I almost just wrote "I hope you can get some perspective", but that's wrong because your perspective is dead on. It's just that living with problems seen so clearly can be difficult. Maybe you can take some inspiration from some of your successful patients -- perhaps some of them have found ways to live well in our frustratingly imperfect world. I imagine that you've helped them to do so.
Your post has motivated me to (try to) finish one of my own on the problems that you raise as they are manifested in the history of documentaries about schizophrenia. Just...watching all of that pain can be trying.
Thank you Michael, I appreciate that :)