In a lecture he gave in October 2008 Consultant Psychiatrist Dr Pat Bracken spoke strongly in favour of engagement of psychiatrists with consumers of mental health services.  He put it rather strongly actually: 

‘If we say that we are working to develop user-centred services, training and research programmes then is it simply unethical to carry on as if the user movement did not exist’.

True to this insight, during my time as a psychiatric trainee I’ve had very little to do with user organisations, and they have therefore had little or no impact on my thinking or clinical practice*.  Just like Bracken says, for me they have not existed.  I am unable to say if this is the experience of all psychiatric trainees, or whether my training establishment is particularly indifferent, but I fear that I am not a unique case.  This must be a regrettable oversight.  Any sensible commercial entity (to which health services are becoming increasingly compared) listens to people who take the time to lodge a concern, knowing that if they do not, not only will their disgruntled customer brief others of their dissatisfaction, but also that they will be missing an opportunity to improve.  Within psychiatry, patients can make complaints and are sometimes asked to participate, but they act predominantly as advisors and expertise still resides with professionals. 

Why, you might say, does this matter, and why should we single psychiatry out on this?  Perhaps we should not; I personally have seen from working in other medical specialties that psychiatry’s reluctance to engage with user groups is shared by other branches of medicine where there reside doctors who are very unwilling to engage with patients.  Many people return from a stay in a hospital medical or surgical ward with reports of offhand medical staff and have been so uninvolved in their care that they are barely aware of what has happened to them.  However, whilst psychiatric disorders resemble those of physical medicine in many ways, their formulation cannot easily be captured with the same lexicon and the interaction between psychiatrists and their patients is different.  You can, at least in theory treat, a patient’s coronary arteries without so much as exchanging the time of day with them.  A cardiologist who takes into account their patients’ community role and psychological well being may have more satisfied patients, but it is not their primary business.  Psychiatry, on the other hand, deals with thoughts, feelings and behaviours and is entirely cited in the social world.  Our outcomes are less mechanical and more nuanced than those of other parts of medicine.  We have power to define normality, to bestow stigmatizing labels and to take freedoms where we think fit**. 

Psychiatric disease is often chronic, so a beneficial relationship between doctors and patients can only be to mutual benefit.  The fuller dialogue with patients and with user groups could lead us to devise services that genuinely engage people with mental health problems and inform our theories as to the nature and boundaries of psychiatric illness.  Such engagement will lead to responsibilities for our patients too; they, as well as the wider public need to be will to be understanding over the particular areas of difficulty in our practice, such as the use of the mental health act.  Recognition will also be needed of the fact that user groups do not speak with one voice and potentially have contradictory messages. 

If you have worked with user groups in any capacity, please leave a comment below and tell of your experience.

***

*Criticism of psychiatry from former users is, of course, not new.  In 1620 for instance the House of Lords received the ‘Petition of the Poor Distracted People in the House of Bedlam’ a complaint against the inhumane treatment of the Bedlam Asylum inmates. 

** Not that I was there, but this transcript of a 2006 debate organised by the James Naylor Trust gives an idea of how upset some people are with psychiatrists.

Links:

Users’ movement and the challenge to psychiatrists - 1998 British Journal of Psychiatry

There a debate held by Intelligence Squared tonight Psychotherapy has done more harm than good.  Lord Layard and Jeffrey Masson were talking about it on Today this morning.  Both presented arguments lacking in nuance to my mind.  It’s sold out, but I probably wouldn’t have gone anyway as tickets were £25 (grumble, grumble acting to keep knowledge the preserve of privileged elites… - if anyone is going or downloads the mp3 from iTunes please let me know if it was any good)

This article The woman who hates food is interesting.  MeMe Roth President of the National Campaign Against Obesity appears to have an abnormal relationship with food.  Her parents used to be fat and on the day of the interview she’s not eaten anything and it’s 1530.  I’m not good at defence mechanisms - projection or projective identification?

Today I saw a female patient who has problems with use of multiple recreational drugs and alcohol.  I was the first psychiatrist that she has ever seen, she has however for the past two years been taking mirtazapine - an antidepressant - and this is prescribed by her hospital physician.  I almost never prescribe medications outside a psychiatric remit, however antidepressants are regularly prescribed by doctors whose area of expertise is not psychiatry.  GPs, ITUs and stroke wards often start their patients on these medications, and hospital physicians can also be very fond of them. 

The notion that there is a very common disease called ‘depression’ that can be addressed with the use of antidepressants is very prevalent in our society and although psychiatrists are ‘experts’ in it, the general abandon doctors show with antidepressant prescribing would suggest that its treatment is something on which all doctors have purchase and is not just the preserve of shrinks.  Yet can this be a good idea?  Many doctors’ insight into this area may be no more nuanced than that gleaned from their teaching at medical school, which from my recollection was simplistic and dogmatic.  Is low mood such a problem that we cannot but afford to have all doctors tackling the problem, or has the diagnosis gone feral and now needs to be tamed by expert tamers with chairs and whips?

In truth ‘depression’ is a very difficult thing to define and any doctor who says that they can reliably differentiate it from sadness is deluding themselves.  Our current best shots at a definition, or at least the one that most people agree on, are the vague aggregation of symptoms offered by DSM-IV and ICD-10.  These definitions are so broad however that they stand accused of pathologizing everyday sadness and have in part lead to the ridiculous notion, useful to some, that one in four of our population suffers from a disorder of their mental health. 

Standing aside whether widely used criteria are worthy, most doctors – including psychiatrists - pay little heed to operational criteria, and instead simply going to a doctor once or twice and stating that you’re ‘not quite yourself’ is most often sufficient for a prescription of antidepressants, which is a de facto diagnosis of depression.  It’s illuminating often to ask people who say that they are ‘depressed’ what meaning they attach to this; the selection of responses I have had range from those equating to mild dysphoria to those expressing unremitting misery.  It is also not unusual for a question about someone’s supposed mental distress to be framed in more concrete terms: ‘I’ve got a lot of trouble with my housing’ being an unfortunate favourite.  If the first doctor won’t provide you with antidepressants, the second surely will.  Doctors we feel they must help and antidepressants allow them to avoid admitting the boundaries of their efficacy.

Thus a patient who entered a consulting room simply sad, and often unfortunate, leaves anointed as ‘depressed’ having now a stigmatizing mental health disorder, and as this is a disease that sits independent from a life narrative, other avenues of relief which might have otherwise been explored are tacitly discouraged.  Now take the patient we started with.  Anyone standing next to you at a bus stop would tell you that if someone was already taking four psychoactive substances on a daily basis, then addressing these might be the first place to start.    This is what I’d have said to them, but in this rights-based society if I think this and a patient thinks differently, who’s right?

You might think then that this is a call for psychiatrists to act as gatekeepers to the prescribing of antidepressants.  Actually no, depression and antidepressants are one of the stories of our age, which means that they effect everybody and everyone has a part to play in their sensible use.  I’m not going to go so far as to say that there is no such thing as ‘mood disorder’ but in recently years we have all reimagined humans as intensely vulnerable beings, which inevitably means that people will view themselves in this light.  As the prominence of religion in European communities fades and market capitalism continues to propagate the excluded, medicine has become the place to turn for suffering of all kinds, social, physical and mental but this is no substitute for a supportive community.  They don’t teach us at medical school how to know the limits of our business, so we’ve been simply blundering on.  If all doctors can prescribe antidepressants, then all doctors should be part of the conversation about when we’ve gone too far and we should tell people that they’re a lot tougher than they think.

There is I think an episode of Inspector Morse when Morse, whose investigation has conveniently developed to involve an alluring female psychoanalyst, is told by her ‘I’d love to get you on my couch’.  Not like that of course, and such a clichéd line embodies why treatment of the mind can be so fascinating.  It’s a chance to ask questions that would usually be considered rude, and to peer into people’s psyche, so far as they’ll let you. 

Such curiosity, combined with a dollop of the bizarre is amply sated by Alex Boese’s book Elephants on Acid and other Bizarre Experiments.  Here hoax aficionado Boese covers a wide range of scientific enquiry all of which has been published in scientific journals.  Some of it comprises a freaky sideshow but most of the experiments - despite their boldness – have actually represented a leap in our understanding of the human condition.  It’s predictably psychology heavy; Milgram’s grisly experiments in obedience lead him to conclude ‘if a system of death camps set up…of the sort we had seen in Nazi Germany, one would be able to find sufficient personnel for those camps in any medium-sized American town’.  Meanwhile his erstwhile school classmate Zimbardo was the instigator of the infamous Stanford experiment, were mild mannered college students rapidly lost themselves in their adopted social roles.  Festinger tested his ideas on cognitive dissonance by infiltrating a cult that believed in the imminent end of the world. 

Also mentioned are ultimately unsuccessful efforts to get dogs, having seen a bookcase fall on their master, to seek help; the title tale of the consequences of injecting an elephant with LSD, the effects on cockroaches on racing in front of their peers and the effects of LSD on the terminally ill.  It’s all told with a jaunty lilt and, unlike a lot of books I review here, is easily read on the bus.

I went to a debate on complementary medicine recently, hosted by the KCL Social Medicine Society.  Despite being held on Guy’s Hospital Campus, a supposed stronghold of conventional medicine, the lecture theatre was awash with complementary therapists and when the pre-debate votes were taken the numbers were two to one against critics – like me - of complementary practice.

The speeches for and against the motion, although equally disadvantaged by the lack of anticipated audiovisuals, were, by and large, as I had expected as they rehearsed well known arguments on medical evidence and the primacy of double blind randomized control trials.  What I hadn’t been expecting was the degree of tension between the two viewpoints; for instance several audience members felt regularly moved to heckle Simon Singh, co-author of Trick or Treatment – a paean to evidence based medicine, not content that he is already subject to a libel lawsuit from the British College of Chiropractors.

After the addresses, relations deteriorated further when participation was invited from the floor.  It wasn’t just that some of the points made were verbose and closer to statements than actual questions, the vehemence of the complementary therapy supporters disagreement with a conventional medical approach was striking.  It was almost as if they felt that those opposing their view not only disagreed with them, but did so malignly with murderous intent.

Of course the sample of people I saw was self-selecting, but why would people feel so strongly that conventional medicine, and by extension doctors, wished them ill?  A partial answer as to the schism between complementary and conventional medicine is provided by Bad Science guru Ben Goldacre, who in his recent book lists reasons why ‘clever people believe stupid things’.  His argument is psychologically based: people are biased; see patterns where there is only random noise; see causal relations where there are none and overvalue and seek out confirmatory information.  From these beans a beanstalk grows all the way up to Matthias Rath.

I don’t doubt Goldacre’s assessment, but it cannot wholly account for the hostility which I witnessed.  The supporters of complementary medicine at the debate seemed to feel entirely disenfranchised by conventional medicine, and alienated even from cordial debate.  The root of this emotional intensity may be that although the majority of people tolerate the NHS’s faults and are basically satisfied with the service they receive, some people’s experience of conventional medicine can be poor.  Consider the people who feel unheeded by their doctor who can only allot them seven minutes, or those upset and resentful about their parent who died from the effects of chemotherapy; or those suffering from medicine side effects or whose operations lead to complications. For some, it won’t just be the message, but the messenger too: doctors nearly all come from a privileged swathe of society and our relative erudition and advantage will make some patients, whose achievements may on the face of it seem more humble, feel unpleasantly diffident.

Other factors against doctors are wired in from our training.  Despite modern efforts, it all too rarely leads us to heed that a patient’s experience of receiving their healthcare can be even more important than the healthcare itself and we still tend to see people in terms of aggregations of symptoms, ignoring that most of our patients come to see us for reasons only partially related to an identifiable disorder.  Although improvements have been made and medical schools have pulled up their socks, the MRCPsych and other membership exams give pitiful consideration to the cultural forces behind poor health.    Overall, and especially post graduation, our manner with our patients and our ability to help them in any way beyond a narrow biomedical confine it is not treated as central to what we do but rather something we are expected to pick up as we go along.

Could complementary therapy for its staunch adherents be then one in the eye to all the people like doctors who ‘think they’re clever’ and fail to adequately assess or understand patient difficulties?  Is it an inevitable outcome as the result of some people wishing for a more equal partnership for healing? For the disenfranchised, complementary medicine may be something that they can own, and a haven from the people whose education unfortunately makes them seem intimidating and unapproachable.

Addendum 4 June 2009:  In an earlier version of this email I used the spelling complimentary as in ‘to offer praise’ rather than the correct complementary as in ‘to act as an accompanyment’.  Gradually chipping away at my ignorance….  Indebted to TimA for his wise counsel.

In 1986 whilst working for the now ex-newspaper Today, journalist Alastair Campbell suffered a mental breakdown.  This would have remained a relatively private affair, but Campbell’s subsequent role as Tony Blair’s right hand man has meant that it has since become the second most famous mental health breakdown by a figure in current British public life*.  But there’s a happy ending: twenty-three years later, Campbell has not only become an extremely prominent public figure but has recently won the Mind Champion award for his work to reduce stigma surrounding mental health problems.  As well as representing the anti-mental health stigma campaign Time to Change, his contribution has included the BBC2 documentary ‘Cracking up’, and the novel ‘All in the Mind’.  Accounts of Mr Campell’s breakdown can be found on the internet, of which Wikipedia, One in Four magazine and a Ruby Wax interview provide four viewpoints. 

For my part, and as part of my ongoing project to read every book about mental health ever written, I have just finished Mr Campbell’s abovementioned novel ‘All in the Mind’.  A curious book, and mostly dreadful, it takes place over three days in the life of reputable psychiatrist Professor Martin Sturrock.  Although highly regarded by his patients and colleagues, protagonist Sturrock is a man on the verge of a crisis, his mood nosediving and no less in need than his patients; his personal life is a mess; he is distant from his children, semi-estranged from his wife/in love with a patient and has a penchant for visiting prostitutes. 

Besides breathing and standing up straight, Sturrock’s psychiatric work is the only thing he seems to be able to do to his own satisfaction.  Perhaps because of this he feels toward his patients a great responsibility and he is reluctant to cancel their appointments under any circumstances.  The book opens with Sturrock fretting over the consultations he has that day with five people whose own stories are subsequently woven amongst that of Sturrock’s throughout the book: a disfigured young lady, a mood disordered young man, a former victim of sex trafficking, an alcoholic cabinet minister and a straying husband.   Outside these consultations Sturrock’s boundaries with his patients are blurred and during them his methods unorthodox, with his enthusiasm for dream interpretation and conspiracy to mislead a patient’s wife examples.  Sturrock’s patients take his sessions very much to heart, and his sage pronouncements and homework assignments – which they are expected to email to him the night before their appointments - dominate their lives. 

Occasionally All in the Mind’s simple tales of the woe are rather touching and the plot as a conceit is not a terrible one, but the central problem is that Campbell’s prose basically lacks the dexterity to convincingly render his characters’ mental states on the page and more than once the writing was so leaden that I wondered whether a blood vessel might burst in my eye.  A brilliant study of depression this is not, despite Campbell’s first hand experience. Furthermore, although it would be a mistake to come down on a work of fiction too hard for lack of verisimilitude, I do wonder whether Campbell has talked to a psychiatrist about what the job is actually like; Sturrock’s enmeshment with his patients is never criticised and his clinical unorthodoxy never acknowledged, the narrative being purely concerned with the tale of an excellent psychiatrist whose deftness with patients contrasts his own inner turmoil.  Campbell even goes so far as to suggest that psychiatrists have mind reading powers:

 She would tell herself he was the psychiatrist not her.  He was the one who understood the human mind, not her

***PLOT SPOILER: do not read on if you intend to read this book***

As it informs the experience of the rest of the book I cannot but mention the ending.  During the closing chapters Sturrock’s depression takes a sudden, and frankly unlikely, turn for the worse and a florid psychosis leads to his death as he steps in front of a lorry.  Campbell then uses this tragedy to set up a mawkish and contrived ending, as before he dies Sturrock sends a text message to his wife asking that the patients about which we have read should make speeches at his funeral.  They duly do, and the church is unexpectedly full of people Sturrock has formerly treated, all wiping tears from their eyes.

The coffin was carried out.  Hundreds of mourners, many in tears rose to their feet as Mrs Sturrock and her family filed out behind it: pew upon pew of flawed people come to bid farewell to a man who healed many of them; who preached forgiveness, but could not forgive himself

Oh dear.  Campbell is a novelist only for the most undemanding reader.  He clearly feels grateful for the help he has received in the past, but I fear this is not the way to show it.

Other reviews:

Byron Rogers The mannekins don’t walk The Spectator 12 November 2008
Peter Kemp All in the Mind review Times Online November 2nd 2008
Sahmeer Rahmi All in the Mind review Telegraph 6 November 2008
Derek Draper Inside the sick world of the spin doctor Guardian 9 November 2008 - a notably more positive review than the rest, from the former labour insider turned psychotherapist before he revisited disgrace.

*Can you guess which the best known one is?

It has been estimated that approximately 1 000 000 people die of suicide yearly worldwide  and whilst most studies indicate that people who commit suicide have a disturbance of mental functioning this does not exclude a relatively small number of people who, for whatever reason, might express the wish for an early death but yet lack any state that may impair their mental function.  For these people the paternalistic approach applied to many with a desire for suicide appears less appropriate and has lead to the notion of a ‘rational suicide’.  Many people feel strongly that this option for rational thinkers to end their lives should be available and argue that there is a historical president; it was in reference to manner of Socrates’ death that Compassion and Choices, an American euthanasia pressure group, was initially called the Hemlock Society.

The emergence of rational suicide as a concept has happened within a framework of contemporary era cultural, technological and philosophical shifts where individualistic attitudes lead people to treat their own goals and desires as paramount whilst advances in medical treatments have lead to increased lifespan.  Therefore at the end of life we are both encouraged, and afforded more opportunity, to contemplate the manner of our own passing.  Judgement of suicide has simultaneously moved away from assigning a successful suicide to be a moral or religious failure towards one where most suicides have come to be seen as the result of disturbance of mind.

Werth and others have suggested criteria under which a rational suicide should be allowed.  That these are notably circumscribed reflects the negative value that suicide generally holds and the concerns of others with this approach.  Proposed are that for a suicide to be considered rational the person in question must have an unremittingly hopeless condition, should make their decision as a free choice and have engaged in a sound decision making process, including assessment by a mental health professional.

Despite the face validity of this line, analysis of what is meant by ‘rational suicide’ and its implications reveal a more nuanced situation than the casual inquirer might anticipate.  From the definitions of the word ‘suicide’, taken from the latin sui meaning ‘of oneself’ and cidium meaning ‘to slay or kill’, and that of rational, an act that it is characterized by reason or is intelligible, sensible, or can be understood , one can surmise that ‘rational suicide’ is self slaying that is characterized by reason or ‘makes sense’ to others .  The arguments in favour of rational suicide generally come in two flavours.  The first emphasizes the need to respect an individual’s autonomy, the modern meaning of which was developed by the philosopher Kant.  In common usage it implies ‘being one’s own person or being able to act according to one’s beliefs or desires without interference’.  Kant expressed it as a respect for persons and wrote that to violate a person’s autonomy is to treat them as a means rather than as an end in themselves.  The ‘right to die’ is then an expression of the most extreme form of autonomy, that is the right to choose the time and manner of one’s passing.  The second argument in support of rational suicide involves the ability of an individual to make rational assessment of utility or ‘good’ that is gained by ending their life and here proponents argue that suicide can provide freedom from painful and hopeless disease.  In this argument the consideration that an individual has for their quality of life is of paramount importance.

However the concepts of autonomy, utility and rationality alone are inadequate arguments for the acceptance of rational suicide as none are ever identifiable in so pure a form as to be considered a philosophical trump card.  Werth’s guidelines are first and foremost pragmatic and with an irreversible decision at stake the standards of rationality must of necessity be high.  To come to a conclusion that an act or intention of suicide is reasonable is not a straightforward matter.

We must also recognize that in seeking a rational suicide, the components that inform this decision are culturally determined, thereby introducing considerable subjectivity and possible external disagreement.  Furthermore if the decision to end one’s life is informed by persistent suffering, then it is unlikely to be made on entirely non-emotional grounds and likely to be subject to cognitive distortions.  It is a curious position to seek to solve a problem in life, by ending the life itself and those intending a rational suicide would presumably actually prefer to be alive, just not under the current circumstances, indicating the presence of significant ambivalence regarding their decision.

There are few people who would argue that autonomy for a patient, at any stage of care, is not important.  However when we respect autonomy we are respecting a person’s right to exercise their right to make independent decisions about their life and these decisions will be made on the basis of considerations which are consistent with a person’s moral values or a personal code.  These values or code would ideally be independently derived; however this is not possible as people are heavily influenced by such things as their culture, parents and friends.  Thus the sense of autonomy as the exercise of independent thought is compromised.

Alternatively, if one wishes to frame rational suicide as the outcome of an audit of a life’s merits and demerits a pertinent question is what the continuation of this life is to be weighed up against.  If the decision is to be truly informed this should involve gaining all possible facts and imagining all consequences.  However since the experience of being dead is entirely unknown it is questionable whether it is possible to adequately foresee the outcome of one’s actions in this regard.

These concerns indicate that it may be difficult to satisfactorily reach a conclusion that rational suicide is possible.  The concept of a suicide being ‘understandable’ is probably more meaningful and suitable although may not carry the same weight.

Comment on this piece

Life is a disease so cut the bullshit please

Further reading:

Autonomy, rationality and the wish to die Clarke Journal of Medical Ethics 1999;25:457-462
A Primer on Rational Suicide and Other Forms of Hastened Death Werth and Holdwick The Counseling Psychologist, Vol. 28, No. 4, 511-539 (2000)
Rational suicide: uncertain moral ground Rich and Butts Journal of Advanced Nursing Volume 46 Issue 3 270 - 278

Encyclopedia of  death and dying - suicide types

Suicide - a rational choice?

The economics of suicide - Slate magazine

Thought for the day 9 June 2009

Addendum 23 June 2009 Neither euthanasia nor suicide but end of life choice,  Guardian 23 June 2009.  More about physician assisted suicide than rational suicide but the comments are interesting, as they touch on many of the issues raised above

One of the constant criticisms of psychiatry that it is heavily influenced by pharmaceutical companies in whose interest it is to encourage as many people as possible to take medication.  This is not to say that the benefit to society from the products of drugs companies has not been massive, but we should not, simply on this basis, assume that the interest of drug companies and the desires of doctors and patients are identical.  There are significant overlaps, but in one fundamental respect they come into conflict: pharmaceutical companies are answerable to their shareholders and thus above all need to maximize profit and their market share.   Put another way, human beings can survive without endless drugs to cure every possible ill but the companies that provide them cannot.

Psychiatric prescribing has been a particularly rich picking for pharmaceutical companies.  A large proportion of the global drugs spend is on psychoactive drug and in the UK between 1991 and 2001 prescriptions of antidepressants rose by 173%.  Partly off the back of this drug companies have become some of the most profitable organizations in the world.  In 2002 the combined profits for the ten drug companies ($35.9bn) in the Fortune 500 were more than the profits for the other 490 listed businesses put together ($33.7bn).  As their profits have increased, so have the amount governments and individuals have spent on their products.  In the UK the per-person government health care spending went up from $84 in 1960 (3.9%GDP) to $977 in 1980 (5.6%GDP) and reached $2160 in 2002 (7.7% GDP – all figures adjusted for inflation). The global spend on drugs increased from $20bn in 1972 to $500bn in 2004 (not adjusted for inflation).

Drugs are central to modern psychiatric practice and also to thinking about the nature and aetiology of mental disorders.  Arguably the primacy of concepts such as depression, social phobia, attention deficit and hyperactivity disorder owe much to pharmaceutical company intervention and psychiatric disorders provide opportunities for increasing product sales as, being poorly understood, they allow scope for expanding definitions of sickness to include more and more areas of social and personal difficulty not previously within the medical realm.  In addition the influence that the pharmaceutical industry wields has helped to create and reinforce a narrow biological approach to the explanation and treatment of mental disorders and has led to the exclusion of alternative explanatory paradigms. Furthermore the coercive function of psychiatry has also been strengthened by the continued promotion of the idea that that psychiatric disorders are akin to medical conditions and therefore amenable to technical solutions in the form of drugs the benefits of which we have a duty to impose.

Pharmaceutical companies spend a vast amount of money on marketing, an activity which is often aimed at doctors, on whom they must rely in large part for the distribution of their products.  Sponsorship is given to academic meetings providing access to the leading doctors of the future.  Although a representative’s gifts may be relatively small, even ones of negligible value can influence the behavior of the recipient in ways the recipient does not always realize.  There is also disquiet about various aspects of research and the licensing process.  Drug companies have repeatedly been shown to bury unflattering data.  Even drug trials can be considered as a form of marketing as they introduce physicians to drugs early.

Any invective on this subject should not of course just be levelled at psychiatrists, as it effects all branches of medicine but psychiatry has arguably been one of the most vulnerable specialties.  We are rapidly becoming, or indeed have become, a society that seeks a ‘pill for every ill’ and one that looks for simplistic, technical solutions to complex social problems. This helps to divert attention away from the profound social and political changes that have occurred during the last few decades. But for our part as psychiatrists and doctors we should, whilst recognizing the contribution that pharmaceutical companies make, seek not to collude with practices that are against the best interests of patients and of the wider society.

For further information on this subject the following are excellent:

Is Psychiatry for sale? - the astute reader will see that I’ve pinched some of her arguments.  It’s a short closely argued polemic.  But be warned - I once presented it in a journal club and found few supporters.

Big Pharma by Jackie Law.  An entire book on this subject.  Here she talks about it on R4’s Start the Week.  Here’s her blog

Bad Science by Ben Goldacre.  Everyone’s favourite exposer of folly has a chapter on this in his book.  I note with some envy that it’s the 13th best seller on Amazon.  I’d be lucky to get 13 comments on this blog in a month.  One can but dream….

No free lunch

John Cale, Welshman, and former member of seminal rock band the Velvet Underground was interviewed in the Guardian this week.

… what about the night Andy Warhol got the Velvet Underground to play a convention of psychiatrists at Delominco’s steak house? The psychiatrists were appalled. “That was revenge - Lou’s revenge,” Cale says, “and I was all for it.” As a teenager, Reed had been given electric shock treatment to “cure” him of homosexuality. “Lou and I were going to put out a record with his psychiatrist’s letter on one side and my arrest record* on the other,”

The Velvet Underground were a band formed in the mid-1960s by Lou Reed and John Cale together with Mo Tucker and Stirling Morrison.  Although their lifespan was brief they combined the energy of rock with the sonic adverturism of the avant-garde.   Pop artist Andy Warhol was their manager and their first album famously featured a large yellow banana sticker and the instructions ‘peel slowly and see’.  Andy Warhol had been invited to speak at the annual banquet of the New York Society for Clinical Psychiatry and he decided to take the the band along with him as ‘a kind of community action-underground-look-at-your-self-film project’

The psychiatrists who turned out in droves for the dinner, were there to be entertained - but also, in a way, to study Andy. “Creativity and the artist have always held a fascination for the serous student of human behavior,” said Dr. Robert Campbell, the program chairman. “And we’re fascinated by the mass communications activities of Warhol and his group.

“I suppose you could call this gathering a spontaneous eruption of the id,” said Dr. Alfred Lilienthal. “Warhol’s message is one of super-reality,” said another, “a repetition of the concrete quite akin to the L.S.D. experience.” “Why are they exposing us to these nuts?” a third asked. “But don’t quote me.” source

I really wish I could have been there.

The second the main course was served, the Velvets started to blast and Nico started to wail. Gerard and Edie jumped up on the stage and started dancing, and the doors flew open and Jonas Mekas and Barbara Rubin with her crew of people with camera and bright lights came storming into the room and rushing over to all the psychiatrists asking them things like:

What does her vagina feel like?
Is his penis big enough? Do you eat her out?
Why are you getting embarrassed? You’re a psychiatrist; you’re not supposed to get embarrassed…. source

The New York Times reported on the event the next day under the heading, ‘Shock Treatment for Psychiatrists’

Excerpt of the performance

Addendum 17 May 2009:

I found a further account of this in the book Women’s Experimental Cinema by Robin Blaetz.  She’s talking about Barbara Rubin, an underground film maker and a player in Warhol’s factory:

On January 13 1966, Warhol was invited to be the evening’s entertainment at the NY society for Clinical Psychiatry’s forty thir- annual dinner, held at Delmonico’s Hotel. Bursting into the room with a camera, as the Velvet Underground acoustically tortured the guests and Gerard Malanga and Edie Sedgwick performed the ‘whip dance’ in the background, Rubin taunted the attending psychiatrists. Casting blinding lights in their faces, Rubin hurled derogatory questions at the esteemed members of the medical profession, including: ‘What does her vagina feel like? Is his penis big enough? Do you eat her out? As the horrified guests began to leave Rubin continued her interrogation: ‘Why are you getting embarrassed? You’re a psychiatrist; you’re not supposed to get embarrassed. The following day the NY Times reported on the event; their chosen headline, ‘Shock treatment for psychiatrists’, reveals the extent to which Rubin’s guerrilla tactics had inverted the sanctioned relationship between patient and doctor expert and amateur.

Addendum 18 May 2009: Mindhacks has featured this also

*Cale had been previously arrested for possessing chemical substances.

On April 7 2009 I posted about a report by the BBC

The Today Programme reported today that care home children whose behaviour during the 1970s/80s was controlled using large doses  of medication have subsequently given birth to children with birth defects.   The drugs in question included Haloperidol, Droleptan and Depixol.  The BBC have Professor Jeffrey Aronson, professor of clinical pharmacology at Oxford University who says that high doses of such drugs can cause genetic damage.  Presumably he’s suggesting that the drugs cause damage to unfertilized eggs - rather than being teratogenic.  These drugs can currently be given to women of child bearing age.  It’s obviously concerning that large doses of sedatives should be given to anyone without a mental health disorder (or even with…) but if they’re right (nb: it doesn’t sound like a very rigerous report and there could be other causes for what they’re suggesting has happened) this would have wide ranging implications.

I contacted Professor Aronson and he was kind enough to reply

At the moment a possible association between psychotropic drug administration and later birth defects (transgenerational transmission of an epigenetic defect) is hypothetical but worthy of further study.

Transgenerational epigenetic effects have been demonstrated in animals and there is some evidence that they may occur in humans. Diethylstilbestrol was used from the 1940s to the 1970s to prevent spontaneous miscarriages. It was subsequently discovered that the daughters of women who had been given it developed vaginal adenocarcinomas. That was a direct teratogenic effect, albeit an unusual one because of the time it took after birth to occur. However, there is now evidence of a transgenerational epigenetic effect as well–the children of those daughters have abnormalities that include hypospadias in boys [1], menstrual irregularities and possibly infertility in girls [2], esophageal atresia/tracheoesophageal fistulae [3], and possibly ovarian cancers [4]. The data are not conclusive, but they are suggestive. Children of those who were affected by thalidomide may also have an increased incidence of limb deformities [5].

This means that theoretically a genotoxic effect could cause epigenetic birth defects down the line, even though the child was not exposed in utero. Cytogenetic abnormalities have been shown in the blood cells of patients exposed to antipsychotic drugs and benzodiazepines for more than 1 month [6]. I know of no evidence about oocytes.

This combination of observations, taken with the story that has just been reported, suggests that the possibility of a transgenerational epigenetic effect of psychotropic drugs should be investigated. It does not, however, prove the association that has been reported, which is based on circumstantial anecdotal evidence and could be subject to confounding by other factors that the affected women shared. 

1. Brouwers et al. Hypospadias: a transgenerational effect of diethylstilbestrol? Hum Reprod 2006;21(3):666-9.
2. Titus-Ernstoff et al. Menstrual and reproductive characteristics of women whose mothers were exposed in utero to diethylstilbestrol (DES). Int J Epidemiol 2006;35(4):862-8.
3. Felix et al. Esophageal atresia and tracheoesophageal fistula in children of women exposed to diethylstilbestrol in utero. Am J Obstet Gynecol 2007; 197(1): 38.e1-5.
4. Titus-Ernstoff et al. Offspring of women exposed in utero to diethylstilbestrol (DES): a preliminary report of benign and malignant pathology in the third generation. Epidemiology 2008;19(2):251-7. 5. Holliday R. The possibility of epigenetic transmission of defects induced by teratogens. Mutat Res 1998; 422(2): 203-5.
6. Bigatti et al. Increased sister chromatid exchange and chromosomal aberration frequencies in psychiatric patients receiving psychopharmacological therapy. Mutat Res 1998;413(2):169-75.