Some final thoughts on the use of psychiatric medications.
--There is no doubt that many people need psychiatric medication. Their depression, psychosis, or anxiety is so severe that it disables them. And they need treatment--NOW. People have to get back to work. They have to pay the mortgage. Children may have misbehaved so badly due to ADHD that if they do not quickly change they will be expelled from school. Parents may need to quickly calm their explosiveness so as to not emotionally injure their children. Persons with a severe case of mental disorder may be so sabotaging their life that to wait for long term improvement with counseling or psychotherapy is not feasible, even if long term counseling or psychotherapy is the better treatment in the long run.
--But troubling issues remain. How do we know that psychiatric medications are safe and efficacious over the long run, when they are taken for years or decades? I do not believe that there is data to support this.
--I wonder if all of the relevant research on this issue has been published. Has any been withheld? It is generally known that journals will generally not print studies which show that no significant experimental effects have occurred. So if a long term study existed that did not show a beneficial effect of medication over placebo, would it be printed? One important study, the Harrow study*, apparently was turned down by American psychiatric journals. Was it because they considered it poor science? Or because the results went against the grain of accepted psychiatric beliefs?
--Long term effects are hard to research. It is hard to conduct a randomized study for more than a few months. People don't want to abide by a tightly controlled treatment regimen. People on medications during the acute phase of a study may, in the followup phase, want to start psychotherapy or may want to be on no treatment at all. People who have been treated with psychotherapy may want to start medication. And when people do change their treatment, it is not random. They may get off of medications because the medications have made them feel better or made them feel worse. All of this makes controlled comparisons over the long term very difficult indeed. (Hopefully, some very bright researchers will find a way around these problems.)
--If science is providing better and better treatments, then why are rates of mental illness going up rather than down? Why are rates of bipolar disorder going up? The increase in the use of antidepressants and mood stabilizers has been suggested as one possible explanation of increasing chronicity. But very long term trends are difficult to interpret. There are concurrent, ongoing social changes which confound easy analysis. There are changes in the public's use of street drugs, changes in the welfare system that reimburse people who are mentally ill, changed attitudes about reporting symptoms that make people more open about talking about their difficulties, changes in the diagnostic criteria, and changes in the social fabric and social support available to persons. The increasing stresses of modern society also cannot be overlooked as the possible culprit causing a long term trend causing elevations in some psychiatric diagnoses.
--Is there a conspiracy to get people to take drugs that they don't need? Hardly. Is there an economic system which rewards doctors and pharmaceutical companies for treating mental illness with psychotherapy? Absolutely. There is no way to get around the fact that a decreased use of psychiatric medications would severely impact the viability of both psychiatry and much of the pharmaceutical industry. It is a merry round which it would be difficult for them to get off.
--There is no doubt that there are clearly biological foundations for many mental disorders. The research is voluminous. I believe it is incontrovertible. Many mental disorders have biological correlates. Period. But that does not necessarily mean that in all cases, these disorders will respond best to a biologically oriented treatment. It is still theoretically possible that the body remains the best healer, or that psychotherapy is the best approach. (Psychotherapy can be conceptualized as clearing away obstacles which would inhibit the body from healing itself.)
--Some psychologists and mental health professionals would argue that psychological avoidance is the source of many if not most mental health problems--avoidance of internal thoughts and feelings, and avoidance of dealing with problems. Are we as a society encouraging avoidance by advocating the widespread use of medication? And in so doing, are we thus actually making psychological problems worse? Iatrogenesis is the causing of problems through medical treatment. Is that occurring here with an over reliance on psychiatric drugs? If there are natural healing forces in the brain, are the biological treatments we are using helping or hindering them?
--On the other hand, if everyone suddenly went off all psychiatric drugs, would there be enough counselors to deal with the number of patients?
--In the long run the scientific method will correct any current fallacies. Science tends to correct itself. However, in the short run, journal editorial decisions, and grant funding decisions at a federal level could impede some of data which is negative about pharmacotherapy from being collected or published. Science eventually corrects itself, but it sometimes takes a long time. As one author I once read put it, referring to Einstein and the quantum revolution in physics, old scientists don't change their minds, they just pass away. (I'm sorry I don't have the reference; it was in a biography of Einstein).
--People sometimes talk about drugs as being a crutch. They sometimes talk about psychotherapy in the same way. But I believe that misses the important point. Crutches are good things. Or at least I would think so if I broke my leg. But a crutch is a temporary thing. It allows healing by taking the stress off of the body. All medical treatments, whether they are pharmacotherapy or psychotherapy need to encourage the body in its own natural healing. And if they cannot encourage natural bodily (or brain) healing, they at least need to permit it to occur. (This may seem to contradict my point about the use of psychiatric medications being a way of avoiding dealing with problems. There is considerable complexity in this issue. I believe that in an ideal situation, the psychiatric drugs would be used for a short period of time alongside a psychotherapy plan of helping the person to psychologically deal with issues.)
--Psychiatric research is not necessarily objective. In one research program in which I participated, the results of a study indicated a slight advantage of the antidepressant condition over psychotherapy, at least in the short run (the acute phase of the study; in the followup phase, the cognitive therapy did better than the medication.) A nationally known psychiatrist was highly bothered that the benefit of the medication was not found to be stronger. He insisted that a new more powerful statistical technique be used to look for differences between the different treatments (essentially pharmacotherapy versus psychotherapy). Now, you need to understand that we already had TOP statisticians on the project. But with the use of the new statistic, the effect of the medication condition was a little stronger. This was an example of statistics being used in the service of ideology. It is not for me to say whether the statistic was valid or not. I assume that it was. However, if there had not been such ideological devotion to the medication condition being superior by this one influential psychiatrist, there would never have been such an impetus to look around for another statistic and to perform a reanalysis.
*M. Harrow, "Factors Involved in Outcome and Recovery in Schizophrenia Patients Not on Antipsychotic Medication." The Journal of Nervous and Mental Disease, 195 (2007): 406-414. The study seemed to show that psychotic individuals who went off of their medications did better than individuals who stayed on them. The data is open to various interpretations; but it is surprising that it did not receive more prominent journal coverage. In general, it is surprising that it has not been talked about more widely.
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