Recently an article was published in The Age about a patient diagnosed with schizophrenia being forced by the courts to endure compulsory monthly injections of the anti-psychotic drug Paliperidone, which he doesn’t feel he needs. He’s able to make his own decisions, and he’s of sound mind generally, yet unlike most patients that can opt out of their treatment, he is forced to endure regular injections or face arrest. Doctors wouldn’t force chemo on a cancer patient, nor force a Mormon to get a blood transfusion. It turns out that this unfair compulsory court mandated treatment has been going on for some time and has only made the headlines now because people are speaking up about its unethical implications. This raises questions about psychiatric practices and the ‘medicate now, ask questions later’ culture that seems to be the status quo.
I experienced this kind of treatment from the first psychiatrist I went to. I had been on anti-depressants for a while and my symptoms began to escalate. The psychiatrist at the time treated me as if I had bipolar, without diagnosis; I was suffering severe depression, anxiety, agoraphobia and manic episodes. This doctor eventually prescribed high doses of lithium, along with high doses of the antipsychotic drug quetiapine or Seroquel as it’s mainly known as, along with a high dose of fluvoxamine an anti-depressant. Prior to this regimen, he tested multiple medications on me, often with no wean-off period, and with very little consultation, and often, no explanation at all. The medications I was on were extremely sedating, so I was always lethargic and sleeping throughout the day. I was numb and would describe myself as ‘zombie’ like. People noticed I had ‘the light’ out in my eyes and I had slow response times when it came to conversations or reflexes. I was basically on auto pilot. I attempted study at the time, but the medication made it impossible to concentrate so I had to defer before I affected my academic record. Deciding that I couldn’t live like this, especially with the escalating cost of the medication he’d prescribed without diagnosis, I began to see a new psychiatrist. One with a different approach to treatment, and medication.
Our first session he commented on the fact that I seemed ‘out of it’ and he noticed my slow response times. My partner, Toby, was in the session and answering most of the questions because I was basically mute. He is Dr Larry Hermann and he changed everything. With a few simple questions he identified that I did not have bipolar. He recognised that my symptoms of mania were in fact side effects of the medication I had been prescribed. So, the first thing he did was slowly take me off the medications I was on, and I was fine. No more manic episodes. We proceeded with psychotherapy as my main treatment, and he did prescribe an antidepressant Mirtazapine to be used short-term with an exit strategy in place. Dr Hermann educated me on the effects of long term use of medications and its implications on mental health.
Many psychiatrists in the field disagree with his methods, perpetuating the myth that people need to be medicated constantly and continuously in order to treat mental illness. Dr Hermann believes this is counter-productive and makes the illness worse if the patient is kept on medication long term. He believes there is a place for medication, but it must be short term with an exit strategy in place or else patients will start showing side effects as I did.
He referred me to a book called ‘Anatomy of an epidemic’ by Robert Whitaker. Whitaker undertakes a study of psychiatric practices in America and the pharmaceutical companies that fund most of the research that pushes the pro-medication agenda. Whitaker states that the number of people on disability pensions due to mental illness in America has sky rocketed in the last 20 years or so. Even though there are these so called ‘magic bullet’ drugs that are marketed to treat mental illness being pushed by psychiatrists, the number of people on disability is increasing, thus questioning whether these drugs are doing more damage than good. If they were, in fact, magic bullets, the number of people on disability pensions due to mental illness should be decreasing not increasing. He acknowledges that psychiatric medications do work but believes they must be used in a “selective, cautious manner. It should be understood that they’re not fixing any chemical imbalances and honestly should be used on a short-term basis.” He posits that the drugs patients receive can perturb their normal brain function. My psychiatrist Dr Hermann agreed to be interviewed for this article about my personal treatment and his general outlook on treatment by medication and psychiatry practices.
What were your first impressions of me during our first sessions when I came to you with a bipolar label, and list of my medication history?
Dr Hermann: I remember you were heavily medicated Diego. So much so you could hardly speak at all and certainly not able to describe your history in any detail. Only your partner was able to provide some information at that time. As often happens when patients get referred to me they are on a few different medications as were you too. A bipolar diagnosis often means a combination of an antidepressant, a mood stabiliser and an antipsychotic.
What were your reasons for debunking my bipolar and what was your personal diagnosis of me?
Dr Hermann: I’m not sure I’ve ever ‘debunked’ the bipolar label as I never really needed to. What I mean is in psychiatry the so-called diagnoses aren’t true diagnoses in the medical sense. They are descriptive labels saying something about the kind of symptoms a person has. And when I can see medications aren’t helping someone or worse, still making them worse (as you were), then it just makes sense to reduce them and attempt more psychological and social interventions.
Why do you think there is a culture of psychiatric treatment heavily reliant on medication? Is this an ‘old school’ way of treatment approach or is this the paradigm to this day?
Dr Herman:Modern day psychiatry places a large emphasis on the so-called bio-medical model. This means there is an assumption psychiatric illness are at rock bottom brain diseases. But the problem is the science we have available does not support this assumption. There is no evidence mental illnesses are caused by so called chemical imbalances or neuronal disturbances. Genetic inheritance is recognised, but all this really tells us is people can inherit vulnerabilities to mental illness running in families. So, it is both ‘old school’ and current. Well as old school as the 1960’s onwards when psychoanalytic treatments were gradually abandoned by many within psychiatry and with the advent of the discovery of various drugs that could be used in psychiatry.
What are the implications of long-term medication treatment?
Dr Herman:Generally, very poor with a few exceptions. There is an increasing evidence base long-term use of psychiatric medications is harmful in varying degrees for most people. I tell this to all my patients and try as much as I can to help reduce their medications if not cease them altogether whenever and wherever possible.
When is it appropriate to prescribe medications as part of treatment?
Dr Hermann:There is no really clear answer to this. The answer can be as varied as practitioners’ beliefs as well as patients’ preferred approaches. What we do know in psychiatry is many conditions can be managed very well without the use of medications or minimal use of medications. Many psychiatrists believe medications are mostly good and so prescribe them a lot, but I believe they are mistaken and are not paying enough attention to when they can be harmful.
What are the biological implications of mental illness and medication treatment?
Dr Hermann:Unless some new major new future discovery were to occur we just don’t have any evidence mental illness is caused by some biological factor. Medications while not correcting any so called chemical imbalance can still be useful in short term approaches for patients that are acutely distressed and in need ofsomething to help calm them, or sedate them, or tranquillise them.
Is the chemical imbalance theory a myth as according to Robert Whitaker, or are there other factors that contribute to mental health conditions?
Dr Herman:The chemical imbalance theory is most certainly a myth. Scientists and leading psychiatrists do acknowledge this, but the pharmaceutical companies conveniently keep the myth going as it suits their bottom line. And many doctors, under pressure from patients hoping for a quick fix, are quick to prescribe medications as it can be more lucrative for them and they don’t have to do the harder work of talking and listening to their patients. And so, they will often to this day still tell their patients they have a chemical imbalance and that’s why they need to take their medications.
What are your views on mandatory treatment by medication?
Dr Hermann:I think this an area wide open for abuse. Psychiatrists, I believe, should be doing much more to reduce such practices. Firstly, like I said before long term treatments with psychiatric medications is often harmful. And secondly, we as psychiatrists are supposed to be guided by medical ethics which includes principles like first do no harm, informed consent and absence of duress. Sometimes I think very acutely disturbed patients may require involuntary admissions who are a risk to themselves or others. But I don’t agree with patients being forced to take long term medications if they prefer to seek other treatments approaches or even none at all. We should all have the basic right to accept or reject treatments offered to us.
What should people look out for when they see a new psychiatrist?
Dr Hermann:People should probably ask themselves how much they want a treatment consisting of medications or of talking therapy. There are practitioners who do both but the quality of psychotherapeutic skills (which is the talking therapies) amongst psychiatrists varies a lot. Asking any new psychiatrist these things would be good idea.
What traits do you believe an effective psychiatrist who has the welfare of their patients as their number one concern have?
Dr Hermann:Above all else being a good listener. As well-being empathic and always ready to help a patient develop better understandings of themselves. As well giving them useful ways to cope better. It’s well known in psychotherapy training that the relationship between patient and doctor is probably one of the most important healing factors. I’ve experienced and seen this with many patients over the years. It may not sound very ‘sciency’ or cutting edge but it is undoubtedly a very powerful and effective ingredient in good therapy.
Dr Larry Hermann (MBBS MPM FRANZCP Cert Child Psychiatry) practices in Melbourne, Australia.