As a child, I frequently visited my grandparents in a small Georgia town. They lived in an old Victorian house that was filled with wonderful cousins and "show people" – friends from their earlier days as wandering Vaudevillians who passed through town. It was a magical place etched forever in my mind. One of my favorite things was visiting the old couple in the cottage next door. The husband had Diabetes in a time when that was difficult to manage, so he was rarely seen. But the wife, an elderly lady with multiple deformities from Rheumatoid Arthritis was always on the porch, glad to see me, giving out various treats and telling magical stories of her own. She called me her "pal." She had been a traveling Vaudevillian herself until she was stricken with a storm of arthritis that left her barely able to get to her front porch, much less sing and dance. So her stories were of her pre-RA adventures going from town to town and doing shows on the Mississippi River boats – the vacation cruise liners of the day. She loved telling those stories and I loved hearing them. In medical training, it never occurred to me that my choice of specialties, Immunology and Rheumatology, had anything to do with my childhood "pal," but there’s little question in my mind now that she was perhaps the deciding factor [in that place that runs in the background of things].
In the comments, the discussion turned to the writing of Joanna Moncrieff [eg How do psychiatric drugs work?][see also not with a Hamilton Rating Scale…]. She contrasts a disease centered model [the medication treats the disease itself] and a drug centered model [the medication creates an altered state, and the therapeutic effects are secondary to the altered state]. In the comments, there was an argument about the utility of her point. I avoid taking sides when people I respect argue with each other and try to just listen to learn, seeing argument and debate as our greatest legacy from the scholars of old. But I thought I’d add in my own thoughts about Dr. Moncrieff’s point.
When I first read Dr. Moncrieff’s writings, I didn’t get it. I already thought what she said. I had never had a single moment in my life thinking antipsychotics were disease-specific. For that matter, I only thought antidepressants were disease-specific for a short time after a particularly eloquent lecture in my Internist years of yore [I got over it quickly]. And one would have to be blind not to notice that both groups of drugs could and did create altered states. I had a similar reaction on reading Robert Whitaker’s books when he talked about the dangers of medications and particularly their their continual use. I agreed with him, but I always had. I knew that many recommended keeping people on antipsychotics all the time to prevent relapses, but I also knew that patients often didn’t like taking them and stopped. I had seen enough obtunded states and Tardive Dyskinesia to know that I wanted no part of causing either. And I’m also old enough to have seen the patients like those rescued by Dr. Brooks, crippled by years of unmodifed psychotic illness – crippled in a different way from my childhood "pal," but crippled nevertheless.
And I’ve heard activists talk about psychiatrists drugging patients for my whole career – like it’s something we want to do or don’t understand the consequences of or enjoy. And I listened to Dr. Szasz’s point about the myth of mental illness – even read some of his books. And I’ve heard the recommendations and read the guidelines for "staying on meds" ad infinitum. And when I was a chief resident and later a training director, the residents and medical students quickly learned not to present a case to me with "stopped taking her meds" as an explanation for a relapse, knowing they were in for one of my diatribes that started with, "I wonder why she stopped taking her meds? Let’s go ask her," as I marched them en masse to the ward to see the patient.
I understand why people who work in some places, particularly mental health centers or academic jobs, gravitate towards the "stay on meds" end of the spectrum. Patients going off meds do frequently relapse. It’s not very good for them [and it's exhausting]. And I understand why people who see the long term consequences of these medications come to oppose their existence. I decided that I had to make my own peace with all of those things and I had trouble getting there when I thought about "all patients." I am by training and preference an n=1 doctor and what usually happens when I try to think about "all" anythings is that I end up with a headache. I also see physicians as advisers and so the involuntary stuff isn’t my cup of tea. I’m actually pretty good at it, but I just don’t like it [which is probably why I was good at it]. So public mental health wasn’t going to be my choice, even though by temperment and history, I’m afflicted with a "do gooder" gene.
What I decided was that my job was to learn everything I could learn about these medicines and the illnesses they were used to treat, and then deal with one patient at a time – the ones that saw me as their doctor and I saw as my patients. That’s the way I learned to be a doctor and it was, in my opinion, the right way to do things. I followed a reasonable number of patients with psychotic illnesses over the years. I always aimed for them to be medication free, but only occasionally achieved that goal. We had to settle for either intermittently medication free, or medications minimal. I learned that if I was more liberal with antianxiety drugs than usual, I could minimize the antipsychotics more easily because the patients tended to use them for their anxiety. To be honest, the Rheumatologists who had taught me to carefully manage their even more toxic medications were more helpful than the psychiatrists or their guidelines in my own work.
I personally believe that these patients are really helped by long contact with professionals and others who know their illnesses, vulnerabilities, and pitfalls. I believe judicious use of neuroleptics is an important, and sometimes essential, part of the picture. And I agree that the best way to work is collaboratively as an adviser rather than as an authority figure. As for Dr. Moncrieff, I came to see why she says what she says by listening to the KOLs and reading their guidelines. They need to hear it. But I see that point everywhere in interventional Medicine. As an old man, I guess I see most "meds" as poisons or potential poisons. The skill is maximizing the useful effects, minimizing the noxious effects, and living with the constant terror of doing long term harm always sitting on your shoulder. I now think that’s what Joanna Moncrieff is saying and if I’m right, I agree with her. I wish she’d aim it a bit more towards the people who most need to hear it, and not at those of us who have always known it.