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.