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CAN YOU ALWAYS BELIEVE YOUR PSYCHIATRIST?
There is an old
saying that goes “He lies like a physician”. Although
this belongs to a bygone era when the term “psychiatrist”
had not been coined people still sometimes mistrust what doctors
tell them and psychiatrists are no exception to this. It is of
course impossible to produce statistics to demonstrate the
incidence of psychiatric disingenuousness and even if a
comprehensive body of data existed there would still be questions
about individual clinical opinion, actual lack of knowledge and
mistakes on the part of particular doctors. However none of this
proves that the practice does not go on or that it does. Rather
than try to answer this contentious question directly I aim to
point the reader in the direction of things that I have myself
been told by psychiatrists and that others have told me
anecdotally with a view to the reader assessing for themselves
whether these are things to which a psychiatrist could reasonably
be expected not to know the right answer and whether there are
grounds to suppose that he/she would have a motive for lying
about the matters.
Something I have been told all too often when I have complained
about problems with memory, weight or sexual function is the
suggestion that it is to do with age. The role of psychiatric
drugs was to say the least played down. When I didn't know as
much as I do now about the effects of psychiatric drugs I was a
bit puzzled by this because my memory was much worse than others
of my own age group, my weight seemed to have gone up as soon as
I was put on certain antipsychotic drugs and I thought I was a
bit young to be getting problems of sexual dysfunction. In fact
all these problems have markedly improved on more modern drugs
and I was only in my thirties when I can remember being told
these opinions. All of these problems are well known side-effects
of many antipsychotic drugs. As to a motive for deliberately
misinforming me about these matters I would contend that the
doctor concerned wanted me to comply with the treatment programme
and may well have thought I would stop taking the drugs if I knew
the truth. Furthermore when the issue of psychiatric staff being
untruthful about the adverse effects of the treatments they dealt
out was discussed at a local Mental Health Forum I used to
attend, it was admitted by a senior nurse present that the fear
of non-compliance with treatment by patients was the primary
reason for withholding information about these matters.
Similarly when I was taking lithium the psychiatrist let me know
that tests on my kidney function were giving slightly abnormal
readings. Rather than admit this was the lithium damaging my
kidneys he equivocated about the distinction between changes in
kidney function and structural damage, obfuscating the issue of
damage caused by lithium, saying it could be a number of things.
This was in spite of lithium being the most immediate candidate
of causation. He did not want to stop the lithium. I took
affirmative action. It was my life and I wasn't going to take
chances with this drug. So I took myself off it and it was little
surprise that the kidney tests improved a little. The
psychiatrist admitted grudgingly that the timing of this did make
it look like lithium was the cause. Why might he have been
disingenuous in the beginning? Compliance again seems the obvious
candidate. I think he was so worried about my stability that he
just wanted me to keep taking the tablets.
More recently I heard that someone had been denied aripiprazole,
the newest antipsychotic drug, on the grounds that it was used
when the patient needed to be somewhat sedated. Given that the
person in question was taking olanzapine at the time this seems a
rather improbable reason since olanzapine tends to be more
sedating than aripiprazole. I have taken both and this is
certainly my personal experience. I could only speculate why the
psychiatrist in question might have tried to mislead this person.
It might have had to do with cost although the difference may not
have been great or it might have been to do with cautiousness
about using drugs that have not been around for many years and
whose long-term effects are thus unproven. Whatever the reason it
seems that the psychiatrist may not have wanted to be open about
it with the patient.
A more general situation can be described that was prevalent
particularly in the 1990s when a whole new generation of
antipsychotic drugs became available. Many psychiatrists were
very reluctant to use the atypical antipsychotic drugs much when
they first came on the market. They have become the norm as a
first choice in treatment of psychotic problems nowadays. One of
the commonest reasons that was given at the time was that they
were no better than the older “typical” drugs. That
very much depended on what you meant by “better”. If it
was just reduction in positive symptoms: delusions,
hallucinations etc., then there was a grain of truth in this
assertion. But if someone's overall quality of life were
considered then for many people it has proven to be wrong. It is
worth noting that “atypicals” such as olanzapine,
quetiapine, clozapine, risperidone, amisulpride and ziprasidone,
are considerably more expensive than the previous generations of
antipsychotic drugs in most cases. The same is true of
aripiprazole which really is part of an even newer generation of
this class of drug.
Life is such that it is usually possible to invent plausible
alternative reasons for things which are not the genuine ones.
Some people are frequently taken in by this but the more
perceptive and knowledgeable can spot the flaws – at least
some of the time. The question is whether psychiatrists at times
withhold information and sometimes do this by giving misleading
or false information to their patients. If they do then it raises
questions as to whether it really is in the best interests of the
patient to do this – it is certainly very undemocratic
– and whether it is in fact counter-productive. As soon as
someone gets an inkling they are being lied to it creates
distrust and can in itself lead to non-compliance with treatment.
I think a lot more people undergoing psychiatric treatment
nowadays know something about the adverse effects of the drugs
they are given than they did 20 or 30 years ago. In my own
experience of knowing people who are to a degree “in the
know” about this it does not usually stop them taking
tablets. In some ways it makes one feel better to know that it's
not all the illness that's giving one problems. It makes the
illness seem that much less. Anxious uncertainty is almost
universal amongst patients when they know little or nothing about
what is being done to them. The idea that people with psychotic
illnesses are quite unreasonable has been greatly exaggerated and
knowing what risks there are associated with the treatments can
remove one level of uncertainty. It may not be the best time to
talk about this when one is in crisis but as reason returns so
does the ability to distinguish the effects of treatments that
are not to one's liking and to want to know the truth.
Because of more patients having knowledge it is probable that
psychiatrists are more open with more patients nowadays but it is
not something that should be taken for granted.
I have only given a few examples in this piece. Readers will know
whether these ring bells for them and whether they have had
similar experiences of their own. If the examples do resonate
with them then it will have been worth bringing this issue out
into the open.