“Trainwrecks”

One of the highlights of the American Psychiatric Association (APA) Annual Meeting is the Exhibit Hall.  Here, under bright lights and fancy multimedia displays, sponsors get to show off their new wares.  If anyone wonders whether modern psychiatry isn’t all about psychopharmacology, one visit to the APA Exhibit Hall would set them straight.  Far and away, the biggest and glitziest displays are those of Big Pharma, promising satisfaction and success—and legions of grateful patients—for prescribing their products.

At the 2012 Annual Meeting last week, I checked out most of the Pharma exhibits, mainly just to see what was in the pipeline.  (Not much, it turns out.)  I didn’t partake in any of the refreshments—lest I be reported to the Feds as the recipient of a $2 cappuccino or a $4 smoothie—but still felt somewhat like an awestruck Charlie Bucket in Willie Wonka’s miraculous Chocolate Factory.

One memorable exchange was at the Nuedexta booth.  Nuedexta, as readers of this blog may recall from a 2011 post, is a combination of dextromethorphan and quinidine, sold by Avanir Pharmaceuticals and approved for the treatment of “pseudobulbar affect,” or PBA.  PBA is a neurological condition, found in patients with multiple sclerosis or stroke, and characterized by uncontrollable laughing and crying.  While PBA can be a devastating condition, treatment options do exist.  In my blog post I wrote that “a number of medications, including SSRIs like citalopram, and tricyclic antidepressants (TCAs), are effective in managing the symptoms of PBA.”  One year later, Nuedexta still has not been approved by the FDA for any other indication than PBA.

In my discussion with the Avanir salesman, I asked the same question I posed to the Avanir rep one year ago:  “If I had a patient in whom I suspected PBA, I’d probably refer him to his neurologist for management of that condition—so why, as a psychiatrist, would I use this medication?”  The rep’s answer, delivered in that cool, convincing way that can only emerge from the salesman’s anima, was a disturbing insight into the practice of psychiatry in the 21st century:

“Well, you probably have some patients who are real trainwrecks, with ten things going on.  Chances are, there might be some PBA in there, so why not try some Nuedexta and see if it makes a difference?”

I nodded, thanked him, and politely excused myself.  (I also promptly tweeted about the exchange.)  I don’t know if his words comprised an official Nuedexta sales pitch, but the ease with which he shared it (no wink-wink, nudge-nudge here) suggested that it has proven successful in the past.  Quite frankly, it’s also somewhat ugly.

First of all, I refuse to refer to any of my patients as “trainwrecks.”  Doctors and medical students sometimes use this term to refer to patients with multiple problems and who, as a result, are difficult to care for.  We’ve all used it, myself included.  But the more I empathize with my patients and try to understand their unique needs and wishes, the more I realize how condescending it is.  (Some might refer to me as a “trainwreck,” too, given certain aspects of my past.)  Furthermore, many of the patients with this label have probably—and unfortunately—earned it as a direct result of psychiatric “treatment.”

Secondly, as any good scientist will tell you, the way to figure out the inner workings of a complicated system is to take it apart and analyze its core features.  If a person presents an unclear diagnostic picture, clouded by a half-dozen medications and no clear treatment goals, the best approach is to take things away and see what remains, not to add something else to the mix and “see if it makes a difference.”

Third, the words of the Avanir rep demonstrate precisely what is wrong with our modern era of biological psychopharmacology.  Because the syndromes and “disorders” we treat are so vague, and because many symptoms can be found in multiple conditions—not to mention everyday life—virtually anything a patient reports could be construed as an indication for a drug, with a neurobiological mechanism to “explain” it.  This is, of course, exactly what I predicted for Nuedexta when I referred to it as a “pipeline in a pill” (a phrase that originally came from Avanir’s CEO).  But the same could be said for just about any drug a psychiatrist prescribes for an “emotional” or “behavioral” problem.  When ordinary complaints can be explained by tenuous biological pathways, it becomes far easier to rationalize the use of a drug, regardless of whether data exist to support it.

Finally, the strategy of “throw a medication into the mix and see if it works” is far too commonplace in psychiatry.  It is completely mindless and ignores any understanding of the underlying biology (if there is such a thing) of the illnesses we treat.  And yet it has become an accepted treatment paradigm.  Consider, for instance, the use of atypical antipsychotics in the treatment of depression.  Not only have the manufacturers of Abilify and Seroquel XR never explained how a dopamine partial agonist or antagonist (respectively) might help treat depression, but look at the way they use the results of STAR*D to help promote their products.  STAR*D, as you might recall, was a large-scale, multi-step study comparing multiple antidepressants which found that no single antidepressant was any better than any other.  (All were pretty poor, actually.)  The antipsychotic manufacturers want us to use their products not because they performed well in STAR*D (they weren’t even in STAR*D!!!) but because nothing else seemed to work very well.

If the most convincing argument we can make for a drug therapy is “well, nothing else has worked, so let’s try it,” this doesn’t bode well for the future of our field.  This strategy is mindless and sloppy, not to mention potentially dangerous.  It opens the floodgates for expensive and relatively unproven treatments which, in all fairness, may work in some patients, but add to the iatrogenic burden—and diagnostic confusion—of others.  It also permits Pharma (and the APA’s key opinion leaders) to maintain the false promise of a neurochemical solution for the human, personal suffering of those who seek our help.

This, in my opinion, is the real “trainwreck” that awaits modern psychiatry.  And only psychiatrists can keep us on the tracks.

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29 Responses to “Trainwrecks”

  1. mara says:

    That’s a good suggestion to see what the person is like without meds. I think psychiatrists don’t do that enough (see how their patients do without meds). They just throw another med at the problem. I’m personally glad that I went on hiatus from meds for several years. I was so drugged when I was young, that when I became an adult I think it was important to see what I was really like. I discovered I wasn’t as bad as doctors and others tried to make me believe. But it also made me want to try meds again to see if I could get it “right”. And I think it has probably been good for my current psychiatrist that I went on a long break. He got to interview me without any meds in my system and he could see what I’m like when I am most fully myself. I think that’s why he hasn’t gone nuts with mood stabilizers and atypicals. He even threw out my bipolar diagnosis. I’m sure certain people would judge that harshly, because not taking your meds is synonymous with being a difficult patient in the minds of some people. But really…I had been drugged from such a young age, that it was hard for me to even know what I was really like. I even thinks this helps me to distinguish between something that I am naturally experiencing and a side effect from a medication.

  2. AA says:

    Actually Steve, the results from the Star D Study, were not just poor. They were fraudulent. That has been conveniently forgotten by your colleagues.

    http://www.madinamerica.com/author/epigott/

  3. annalaw81 says:

    Jesus! I’ve been called ‘annoying…’ ‘irritating’ and what have you.. but not a ‘trainwreck.’ At least not to my face. I only take 2 meds, a benzo and an SSRI, and at very low doses. I insisted on starting slow, and my 1st psychiatrist was cool with that. As I said in an earlier post, a newer doc (the docs in my clinic don’t stay that long it seems) wanted to change my meds, but she was only staying 2 months, I think because my SSRI is being used ‘off label,’ and because she liked another benzo. I said no. If there’s a doc who is going to say, I’ll consider a change. Until then, I”m good. That article makes me even more convinced that maybe I should just get off all meds altogther. Maybe experience some discomfort for a while, but at least I will be “me.” Articles like that – and books like “Unhinged” – have made me more aware of how ambiguous the practice of psychiatry really is, and how, without continuity and monitoring, the cure might be worse than the disease.

  4. annalaw81 says:

    correctin… “If there’s a doc who is going to stay, I’ll consider a change.”

  5. Judy says:

    Mine called me a “pain in the ass” one time. I cannot even begin to imagine any of my other doctors even muttering those words under their breath.

  6. Peter C. Dwyer says:

    Steve – Thank you for deconstructing that guy’s statement so clearly. Your observations of the convention are excellent. I think I understand some of why other psychiatrists don’t see things as you do, but it still surprises me that they seem to go along with it all. I would be very interested in your take on what goes on in the minds of most psychiatrists who are exposed to the same experiences but the contradictions and illogic don’t seem to register with them.

  7. Stop.Psychiatry says:

    Steve, why don’t go a step further and promote that psychiatry is disbanded as a medical specialty? I am a scientist myself in a hard scientific field. What you describe to be the practice of psychiatry, which in my own experience is an accurate description, would have been called scientific misconduct in my field. There is no denying that mental issues are real, but there is an overwhelming body of studies and data that show that not only psychiatry has been unable to reliably link any single mental disorder to a biological marker but that the drugs prescribed to treat this disorders while no better than placebos cause significant side effects. In my case, a combination of antipsychotics with SSRIs, forcibly prescribed to treat OCD, almost damaged my kidneys and liver. It was my decision to not take the drugs that saved them from further damage. I am happy that I could make that decision in America, free from the type of psychiatric abuse that is pervasive elsewhere. You seem to be one of the few psychiatrists that understand what is going on. In a way, your role is similar to those honest priests in the Catholic Church that were aware of the abuse perpetrated by their peers. The most courageous amongst them went public facing the wrath of the Church hierarchy. The cowards stayed shut. What are you guys going to do? As somebody mentioned, the fact that psychiatry tends to pick on the weakest of society is probably the only reason why we don’t see more malpractice lawsuits brought against psychiatry.

    • stevebMD says:

      Stop,

      While you make some excellent points (and I’m sorry for your experience but grateful that you had the insight– and the ability– to overcome it), I don’t know if I necessarily agree with your Catholic-priest analogy.

      Physical/sexual abuse is wrong, irrespective of setting, time, personal position, or any of a dozen potentially mitigating factors. Prescribing antipsychotics and SSRIs for OCD, on the other hand (even forcibly, in some situations) is not only acceptable according to the science, but it is the standard of care. True, a challenge to this status quo is warranted, but would likely fail, particularly when the framework upon which the status quo is erected (ie, the biomolecular theory of mental illness) reinforces this standard.

      To put it bluntly: Jesus Christ never advocated for his children to suffer at the hands of his minsiters, but plenty of my field’s key opinion leaders advocate for the treatment that almost ruined your kidneys and liver.

      • Stop.Psychiatry says:

        See, that’s one of the beefs that I have with psychiatry in general, “plenty of my field’s key opinion leaders advocate for the treatment that almost ruined your kidneys and liver”. That’s a fact, ie that mainstream psychiatry is totally sold to Big Pharma, but consensus does not a scientific finding make, especially given the overwhelming data against the hypothesis that those SSRIs/antipsychotics are better than placebos. Imagine that we designed planes or cars on a similar basis. You’d never know in advance if there is a 50% chance that the plane would fly or the car would work. Would you want to take such a plane or drive such a car? Even a better analogy, imagine that the computer systems that manage your bank accounts work the way mainstream psychiatry works. One day, you might find your checking account depleted of cash. You might think that there is a reasonable explanation for that so you call customer service; they inform you that they cannot tell what went wrong because the transactions that took place in your bank account work well for some customers just they didn’t in your case and there is no way to tell why in your case the result was that the cash evaporated. Psychiatry has too much power for being based in such junk science (thankfully not much here in California although there is no shortage of evil psychiatrists pushing for things such as Laura’s law).

      • stevebMD says:

        Stop,

        I’ll let you in on a little secret. When I was in my early years of residency, I worked in an OCD clinic at a highly respected academic medical center. This was a tertiary-care referral clinic, meaning that most of our patients had been through several psychiatrists and psychotherapists, numerous medication trials, and often several other treatment modalities, and yet still had intractable OCD symptoms. They were, quite literally, at the ends of their ropes.

        The secret is that we practiced almost no “science” at all. Because these patients had been through all of the logical, guideline-based choices already (including surgery, in some cases), we were grasping at straws: adding stimulants, high-dose benzos, atypicals (which at that time were in their infancy), megavitamins– you name it.

        Surprisingly, some patients did well. And, as you might expect, those patients were grateful, if not absolutely ecstatic. Sure, there were others who did not respond, but they did not become the plane crashes or bank failures that you allude to in your comment.

        Fundamentally, I wholeheartedly agree with you– that we ought not put our faith in “junk science”– but the problem with psychiatry is that sometimes “junk science” works.

      • Stop.Psychiatry says:

        Surgery for OCD!!!! Wow, just when I thought it couldn’t get worse :( . I am doing my best to stay away from psychiatry but somehow I feel I have an obligation to those patients who are not as fortunate as I am.

      • Nathan says:

        Dr. Steve,

        1. There are plenty of religious institutions currently and in the past that advocate and protect for all sorts of violence regardless of whether you think it is wrong. Some of the power of religious institutions is that they can shame moral frameworks and exert great influence (even coercion) due to their power, filtering behaviors, thoughts, experiences, relationships, and beliefs through an ever-changing but still controlled by them lens that deeply regulate people’s lives in profound ways (defining what’s right and wrong, influencing what is criminal or not, and differentiating pathological from “normal.” Psychiatric establishments are not dissimilar in that regardless of the rationale of the day (shifty humors, inappropriate temperature, malfunctioning brains, repressed drives, chemical imbalances, distorted cognition, genetic abnormalities, faulty brain circuitry, etc ) they are empowered to set the framework of how individuals, families, and societies view and assess people’s lives, experiences, beliefs, etc., make moral claims, influence criminal justice, and keep the reigns on ever-shifting notions of pathology. Forced treatment many would say is a violence that is plain wrong, and isn’t event acceptable according to science (http://journals.lww.com/co-psychiatry/Abstract/publishahead/Involuntary_treatment_in_Europe___different.99720.aspx).
        I think S.P’s analogy is not too far off in that both the Catholic Church and the American Psychiatry are institutional powers, have direct and discursive influence on people’s lives (even people who are not Catholic or involved in mental health), institutional powers are protected/themselves influenced by political and economic interests, and remain a powerful force precisely because so many fall in line, remain silent, and do not stand up to abuses of power. The standard practice in the church hieararchy was to not press charges on abusive priests, move them to different jobs in different locations (instead of at least defrocking them), and lying to/bullying families who originally had a lot of trust/faith in the institution and the people involved with it. This could be analogous to standard practice in psychiatry to rely corrupted data, lie to people and families about the situtaitons they are in, and to circle wagons around people who blatantly had immoral connections with industry or motivated by greed who profited tremendously at the expense of many suffering patients who sought help from psychiatrists precisely because they were led to believe and to trust the competency and quality of their care.

        2. I think saying “sometimes ‘junk’ science works” is a non-point. It’s the same thing as saying sometimes what is likely to work based on strong scientific inquiry doesn’t work. They are both true. However, when something non-expected “works” sometimes, you have no idea why it works, and it cannot be shown to predictably work in other similar situations, you don’t make the randomly effective treatment a treatment of choice given you have better options. That isn’t science, it isn’t medicine, and it is ultimately unhelpful. It’s really superstition/magical thinking, connecting causes and effects without strong evidence. Scientific process works in probabilities of predictability. There are all sorts of factors always at play. Strong evidence for effectiveness comes from demonstrating high probabilities of accurately predicting responses. I hope at least you told people that there was limited/no science underpinning their treatment, at least then they could have greater informed consent to participate, many choosing to do so because the alternative (doing nothing because everything else failed) was increasingly unbearable. At the end of the day, there may be lots of reasons why people at your clinic got better, there may be a lot of other places/treatments that could have been even better than the ones your provide, you just don’t know. Junk can work sometimes, but it is not science, medicine, or I think ethical to make profession out of it.

      • Nathan says:

        To add, I think the analogy the S.P set up is useful in understanding the disconnect between critics/survivors and psychiatrists in regard to the widespread mistrust of psychiatrists/Psychiatry in general and may psychiatrists who can claim no wrongdoing, maliciousness, or culpability. I think understanding it through a lens of losing faith/feeling betrayed by an institution you originally believed had your interest at heart, like many people’s experience with the Catholic Church in light of the sexual abuse scandals, can be illuminating. There are only a small minority of priests accused/convicted of child sexual abuse, with the vast majority of priests and others in the institution generally very decent folks. However, when the hierarchy chose to protect abuses, deny abuse, and belittle/bully folks coming forward, folks directly and indirectly involved lost a lot of faith in the whole endeavor. Thoughtful priests who saw this, and experienced a lot of anger directed towards them, did not try to point out the differences between them and the rest of their institution. They understood that is was not just individual priests who abused trust or that people put trust in, it was an institution that had a hand in that abuse of trust and that it was an institution people put trust in and then lost trust in. These thoughtful priests welcome people’s anger work hard to investigate and correct internal problems and to rebuild an honest trust.

        Psychiatric critics/survivors do not feel that just their individual psychiatrist let them down, mislead them, coerced them. or anything else. People sought or were forced into psychiatric services because they (or lawmakers) thought that the institution of psychiatry was robustly helpful, trustworthy, based on solid science, and practiced ethically. Regardless of how many psychiatrists are actually doing bad things, the illumination that the whole field has privileged magical thinking of science, has limited efficacy, has corrupt relationships with industry and academia,and has the power to coerce patients and then justify that power by exploiting someone’s desire to get help. I see many psychiatrists just say to patients who had a bad experience, “sorry, there must have been a mismatch between you and your psychiatrist, get an other opinion,” without realizing that the choice of clinician is not what is upsetting to people, is it is the betrayed trust in the institution for the reasons and more I cited. Thoughtful psychiatrists understand this, work to investigate and correct problems within their own institution, and work hard to rebuild trust with patients/public by doing things that indicate trusthworthiness (quality research, cut ties to industry, honest informed consent, stop forced treatment, etc.). The difference between the Catholic Church and Psychiatry though is that many can have faith in the Church just on faith alone. Psychiatry should be and is expected to garner trust through advancing scientific knowledge and demonstrating strong treatment outcomes.

      • Stop.Psychiatry says:

        Nathan,

        Amen to your two posts. Amen to “Psychiatry should be and is expected to garner trust through advancing scientific knowledge and demonstrating strong treatment outcomes”. There are many disciplines around that are based on junk science (homeopathy, astrology,etc). Of course people are free to use or not use the services provided by those disciplines. The problem with psychiatry is that not only it is endorsed by governments, but these governments give psychiatry all kinds of legal powers including the power to deprive people of liberty and the power to forcibly drug (or ECT) people against their will. Geee, it reminds me of the times of the Spanish Inquisition, when they were able to forcibly impose on people their belief system. Why is psychiatry allowed to impose its belief system (since we all seem to agree that psychiatry practices junk science) on society at large? That’s the real scandal.

      • sciencia says:

        “Fundamentally, I wholeheartedly agree with you– that we ought not put our faith in “junk science”– but the problem with psychiatry is that sometimes “junk science” works.”

        Steve, I think you are confusing junk science with the concept of trial and error. Junk science is a subversion of the experimental process, whereby the results of experiments are falsified, misinterpreted or misrepresented to support unjustified claims. There’s nothing inherently unscientific about using trial and error to try to solve problems whose mechanisms of action we don’t understand. (Nothing wrong, that is, as long as you have the informed consent of those involved). At its heart, the scientific method is really just a systematized process of refining trial and error.

        On the other hand, claiming scientific authority when applying experimental results to situations that don’t match the initial testing conditions IS unscientific. I’d argue that somewhere between 99% – 99.9% of clinical applications of even the most rigorously conducted psychiatric trials are prematurely applied in this way. Sometimes, the state of the science isn’t advanced enough to address real world problems. I think this may be part of the reason why people from the hard sciences, like Stop.Psychiatry, feel that many psychiatric practices border on scientific misconduct. (My apologies to Stop for putting words in his/her mouth.)

        Given the number of causative and mediating variables (“complexity”), path dependence and plasticity of the human brain’s organization, I doubt if science will ever be able to produce mathematical models of brain function powerful enough to support individual treatment decisions or “cures” to “mental illnesses”. Personally, I just don’t think the Maxwell’s equations of the mind-brain system are out there to be discovered. Telling patients that treatment courses are “scientifically validated” when they’re only in the process of scientific testing, is an abuse of the respect and authority accorded to science in our society.

  8. Xfu says:

    Steve why don’t you just admit you would have been better off becoming a real doctor, like a cardiologist or a surgeon, and not some brain blaming quack?

    Is it because you ‘want’ to believe the story you’ve told yourself?

    • stevebMD says:

      Xfu,

      I don’t know how sincere you are with this question, but it’s actually a very good one, which has prompted a lot of soul-searching.

      In my case, it’s not so much a case of buyer’s remorse as it is a feeling of having been sold a lemon. My medical and (most of) my residency training were in the heyday of the biological psychiatry revolution (late 90s – early 00s). I was led to believe, in no uncertain terms, that I was witnessing a turning point in how we treat not just serious mental illness, but all sorts of emotional and behavioral problems, with drugs that were far safer and more effective than their predecessors.

      There was just one slight problem. Well, okay, there were many problems, as we now know, but for me, the real test was when I actually started seeing patients. The drugs just didn’t work as well as had been advertised. Or if they did, there were often multiple other explanations for why I saw a response. Even in my own recovery, psychiatry did very little for me (it didn’t hurt me, thank god); instead I benefited from other psychosocial interventions.

      I absolutely want to believe the story I’ve been told. But my tendency to be objective and unbiased– and to think about all aspects of a problem before jumping to a conclusion– prevent me from doing so.

      • Stop.Psychiatry says:

        I have done a bit of research about you and I have to say that first of all I admire you for being so open about your struggles. If you read my first posting where I detailed my case, you’ll see that I was harmed by psychiatry in many ways (psychical, physiological and social) but thanks God I didn’t have any criminal matters to deal with. Still, I am so stigmatized and humiliated by the whole experience that very few people know about it. I think that there is enough evidence to say that the current practice by mainstream psychiatry, basically the random drugging that you beautifully describe in your posting, is a fraud of gigantic proportions. I am as guilty as anybody else that has been harmed by psychiatric practice for staying shut, but what else can be done? I don’t see it realistic that psychiatry is going to willingly acknowledge its limitations. Humans don’t surrender power that easily (and because psychiatrists have the power to involuntarily commit people it’s a huge power we are talking about). I think that if it weren’t because until very recently the only opponent to psychiatry was the Church of Scientology, it was very easy to make “guilty by association” accusations to all those opposed to psychiatry. Guess what, I am absolutely no fan of Scientology but I think we have to admit that they were ahead of the curve of everybody else when it comes to the criticism of pharmacopsychiatry. They were the ones fighting against Prozac 15 years before the FDA finally admitted that it increases suicidality in young people. I am outraged at the whole thing but I don’t know what to do that helps bring the current practice of psychiatry down.

      • stevebMD says:

        Stop,

        When I see the phrase “I have done a bit of research about you…” I never know what to expect!! But the fact of the matter is that my past informs and shapes my present, in very positive ways. I’ve been fortunate enough to overcome many obstacles but also maintain a position where I can possibly do something– even if my role is very small– about the state of modern psychiatry. Thanks for recognizing that.

        The way I see it, psychiatrists are not evil people, nor are pharmaceuticals uniformly bad. Likewise, biological psychiatry is an important science, as it may lead to breakthroughs in our understanding of human behavior. The problem is that the current paradigm sees behavior as primarily (if not wholly) biological, while our science is in its infancy. Nevertheless, this leads to the imperative to medicate, which, in turn, has become the daily work of most psychiatrists. For many reasons (financial, bureaucratic, sociocultural) this is nearly impossible to reverse, although a moment’s thought by even the most devout psychopharmacologist will often create some cognitive dissonance.

        Nevertheless, despite the criticisms of those of us on this blog (and elsewhere), one thing holds true: more often than not, conventional psychiatry works. Call it drug effect, call it placebo, call it whatever you wish. (In my opinion, it’s a combination of true effect, sheer luck, and psychiatry’s ability to make a cogent, plausible explanation for just about anything, particularly to the uninformed patient.) Most patients get “better,” and most patients come back for more. This gives rise to the hubris (and, at times, arrogance) of the psychiatric profession and its unwillingness to accept any alternative explanations. Unfortunately, it also empowers us to give our full support to pseudoscientific justifications, shared delusions about “mechanisms” and “pathways,” questionable (if not corrupt) clinical-trial evidence, and a pharmacological imperative being foisted upon us by a health care system spinning rapidly out of control.

        Other than that, everything’s just fine.

      • Stop.Psychiatry says:

        In my own case, the net result has been that I have stopped all treatments (no more meds/CBT), I have no relationship whatsoever with my European family (who were the ones that initiated the involuntary commitment process), I have promised myself that I will never return to that third world country and I have joined an antipsychiatry movement http://www.mindfreedom.org/ (Scientology is too creepy for me, but I remain convinced that CCHR got the main objections to mainstream psychiatry correct and that the rest are playing catch up with them; it’s really unfortunate that they were the only ones fighting the abuse at the very beginning). One thing that your generation of American psychiatrists don’t fully appreciate is that a series of decisions by the US Supreme Court starting in the 1970s has de facto limited psychiatrists’ ability to do damage on a large scale in the United States. Psychiatric abuse still exists in the US but it is much more rare than it was once (think the 50s and earlier), and limited to extreme cases or outcast of society (homeless, foster children, criminal defendants). Still unfair, but the universe on which psychiatry can freely prey is limited. That is not necessarily true in other countries. In particular, the products of American psychiatric junk science, such as the DSM, are used everywhere even in countries where patients do not enjoy the protections we do in the US. Thus, statements that might sound reasonable in an American context are nothing more than a license for widespread abuse elsewhere. At this point I have nothing but contempt for mainstream psychiatry.

  9. Thanks for the link toward the end of your post. The term “trainwreck,” while clearly derogatory, is not limited to psychiatry and says nothing about treating patients in a sloppy or offhand manner. Patients in the medical ICU are often called trainwrecks while being treated with the utmost care. Psychiatry’s problem is not knowing how the train works, yet having too much hubris to admit it. Our colleagues hustle down to the derailed train, sledgehammer and pry bar in hand, to “do what they can.” Often the result isn’t pretty. I have no objection to admitting a clinical situation is difficult, and even using colorful language to describe it. But if we allow that the case is difficult, shouldn’t that make us MORE cautious when we intervene?

    Your blog has lately attracted comments urging you protest and reject psychiatry generally. Why stay in a field that is so damaged? The answer, for me at least, is that thoughtful psychiatry remains humanitarian, caring, and intellectually challenging — and is not a contradiction in terms. Just because others do it sloppily doesn’t mean you have to. Hang in there.

  10. doctorz says:

    The title of this article reminds me of my 3rd year surgery rotation in medical school. One of my patients had a long term stay in the SICU. He had been transferred to me by a fellow student who had cared for him the previous month. When I inquired as to his diagnosis and other background information during the exchange, the other student referred to him as a “trainwreck”, to which I responded, “Yea, but what’s his diagnosis?”. Turns out, he was actually the victim of a trainwreck…his truck had stalled on the railroad tracks and was met side on by a train traveling at 40 mph. He amazingly survived, but incurred multiple fractures and internal injuries, requiring several surgeries, including a laparatomy. After showing some initial improvement, he had a setback of dehiscence, followed by evisceration, then rallied repeatedly, only to be countered by multiple additional complications…truly a burden of Sisyphus. And yet, he never lost his indomitable spirit before eventually succumbing. As physicians, we fondly recall those patients who have recovered from their illnesses against all odds, but I was indelibly imprinted with the memory of how much this saint inspired me in his suffering. This perhaps was the greatest reward of my training; that is, to have witnessed the potential of a fellow human being in enduring immeasurable suffering, yet maintaining hope through the power of faith, which this gentleman clearly possessed. And in experiencing this, it has instilled me with a personal hope through my own struggles, and one that I have felt compelled to pass on to patients who are on the verge of giving up.

  11. Stop.Psychiatry says:

    After http://blog.stevenreidbordmd.com censored one of the comments I posted in his blog, and following his advise, I have created my own anti-psychiatry blog http://endpsychiatry.blogspot.com/ . You are welcome to visit, comment and spread the word.

  12. Tuppy says:

    Steve, couple of items got me kind of nerved. I am not a frequent reader so maybe it is just how you roll. You talk about how N hasn’t been approved for any other conditions; however you fail to discuss that the company has not attempted to get other conditions approved within the pas t year for N. Sure there are other indications N could be used for; however they have to prove it works in studies which takes time. You talk about how SSRI meds have helped people with PBS, so basically there is no need for N. However you have not talked about how they always do not work for PBA and the recent negative publicity SSRIs are getting due to side effects. Just because one person mentions a patient to be a train-wreck does not mean the whole company is selling the drug the same way. Unlike most meds N works relatively quickly and has shown to be relatively safe compared to other meds. It has also shown promise in other conditions so it might be worth the patient receiving a short free trial compared to an SSRI which could be worse. There have been plenty of success stories regarding this drug and you do not mention anything but negativity towards this. I believe there are plenty of pill pushers out there but its the docs who write the scripts.

  13. Duane Sherry says:

    Steve,

    Psychiatry itself is a “trainwreck”.
    So, what’s next?

    We could all just continue to talk about this stuff for the next couple of decades, or we could begin to take the first steps toward a complete system transformation –

    http://www.madinamerica.com/2012/05/11866/

    Yes.
    It can be done.

    Duane

    • annalaw81 says:

      Yep? I agree w/ Duane. I think there are some folks with new ideas (where are you, aek?) and while we keep shining the light on the things that are wrong with psychiatry, we should (as a people – I’m not a psychiatrist, so all I can do is let my own voice be heard…) begin to Act, not just Talk. Although I doubt a ‘complete system transformation’ will occur any time soon, the smaller steps toward making this discipline more user friendly couldn’t hurt. I realize that some of the changes folks talk and blog about involve more labor intensive activities (talking with patients, not just medicating them), and that then involves questions of funding, there just has to be a better way. I don’t think psychiatry should be “junked” altogether, it just needs to be retooled to make more sense and to reflect whatevre ‘science’ psychiatrists et al are relying on when they whip out their prescription pads, if in fact that’s really necessary. Just sayin…

  14. Sahana says:

    Steve,

    Sure you could pick any other specialty, but now that you know what’s going on in psychiatry, and that you can make a difference, could you see yourself being in any other field? And really, is it only psychiatry? Take a man with a bit elevated cholesterol, prescribe statin instead of advising lifestyle change, and before you know it he has diabetes, soon hypertension, insomnia, sad and irritable mood, memory problem, and you got a cocktail of a dozen meds. Throw in some narcotic pain med for good measure (it’s not a hypothetical case, it’s a close family member of mine, with no family history of any of the above “diseases” in all the known generations, and this trainwreck happened right in front of my eyes!). The whole health system needs a major overhaul.
    I am with all the people who suffered in various ways in all the specialties’ “care”, will “keep trying” to change/improve one life at a time, but can’t emphasize enough of the need for “complete system transformation”. Until then, nothing will be even remotely enough, everything remains suspect.

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