Why I’m not sure that psychiatric medications work

Why I’m not sure that psychiatric medications work

I have a confession to make.  I don’t think what I do each day makes any sense.

Perhaps I should explain myself.  Six months ago, I started my own private psychiatry practice.  I made this decision after working for several years in various community clinics, county mental health systems, and three academic institutions.  I figured that an independent practice would permit me to be a more effective psychiatrist, as I wouldn’t be encumbered by the restrictions and regulations of most of today’s practice settings.

My experience has strengthened my long-held belief that people are far more complicated than diagnoses or “chemical imbalances”—something I’ve written about on this blog and with which most psychiatrists would agree.  But I’ve also made an observation that seems incompatible with one of the central dogmas of psychiatry.  To put it bluntly, I’m not sure that psychiatric medications work.

Before you jump to the conclusion that I’m just another disgruntled, anti-medication psychiatrist who thinks we’ve all been bought and misled by the pharmaceutical industry, please wait.  The issue here is, to me, a deeper one than saying that we drug people who request a pill for every ill.  In fact, it might even be a stretch to say that medications never work.  I’ve seen antidepressants, antipsychotics, mood stabilizers, and even interventions like ECT give results that are actually quite miraculous.

But here’s my concern: For the vast majority of my patients, when a medication “works,” there are numerous other potential explanations, and a simple discussion may reveal multiple other hypotheses for the clinical response.  And when you consider the fact that no two people “benefit” in quite the same way from the same drug, it becomes even harder to say what’s really going on. There’s nothing scientific about this process whatsoever.

And then, of course, there are the patients who just don’t respond at all.  This happens so frequently I sometimes wonder whether I’m practicing psychiatry wrong, or whether my patients are playing a joke on me.  But no, as far as I can tell, I’m doing things right: I prescribe appropriately, I use proper doses, and I wait long enough to see a response.  My training is up-to-date; I’ve even been invited to lecture at national conferences about psychiatric meds.  I can’t be that bad at psychiatry, can I?

Probably not.  So if I assume that I’m not a complete nitwit, and that I’m using my tools correctly, I’m left to ask a question I never thought I’d ask: Is psychopharmacology just one big charade?

Maybe I feel this way because I’m not necessarily looking for medications to have an effect in the first place.  I want my patients to get better, no matter what that entails.  I believe that treatment is a process, one in which the patient (not just his or her chemistry) is central.  When drugs “work,” several factors might explain why, and by the same token, when drugs don’t work, it might mean that something else needs to be treated instead—rather than simply switching to a different drug or changing the dose.  Indeed, over the course of several sessions with a patient, many details inevitably emerge:  persistent anxiety, secretive substance abuse, a history of trauma, an ongoing conflict with a spouse, or a medical illness.  These often deserve just as much attention as the initial concern, if not more.

Although our understanding of the pathophysiology of mental illness is pure conjecture, prescribing a medication (at least at present) is an acceptable intervention.  What happens next is much more important.  I believe that prescribers should continue to collect evidence and adjust their hypotheses accordingly.  Unfortunately, most psychopharmacologists rarely take the time to discuss issues that can’t be explained by neurochemistry (even worse, they often try to explain all issues in terms of unproven neurochemistry), and dwindling appointment times mean that those who actually want to explore other causes don’t have the chance to do so.

So what’s a solution?  This may sound extreme, but maybe psychiatry should reject the “biochemical model” until it’s truly “biochemical”—i.e., until we have ways of diagnosing, treating, and following illnesses as we do in most of the rest of medicine.  In psychiatry, the use of medications and other “somatic” treatments is based on interview, gut feeling, and guesswork—not biology.  That doesn’t mean we can’t treat people, but we shouldn’t profess to offer a biological solution when we don’t know the nature of the problem.  We should admit our ignorance.

It would also help to allow (if not require) more time with psychiatric patients.  This is important.  If I only have 15-20 minutes with a patient, I don’t have time to ask about her persistent back pain, her intrusive brother-in-law, or her cocaine habit.  Instead, I must restrict my questions to those that pertain to the drug(s) I prescribed at the last visit.  This, of course, creates the perfect opportunity for confirmation bias—where I see what I expect to see.

We should also make an effort to educate doctors and patients alike about how little we actually know.  The subjects in trials to obtain FDA approval do NOT resemble real-world patients and are not evaluated or treated like real-world patients (and this is unlikely to change anytime soon because it works so well for the drug companies).  Patients should know this.  They should also know that the reliability of psychiatric diagnosis is poor in the first place, and that psychiatric illnesses have no established biochemical basis with which to guide treatment.

Finally, I should say that even though I call myself a psychiatrist and I prescribe drugs, I do not believe I’m taking advantage of my patients by doing so.  All of my patients are suffering, and they deserve treatment.  For some, drugs may play a key role in their care.  But when I see my entire profession move towards a biochemical approach—without any good evidence for such a strategy, and without a fair assessment of alternative explanations for behavior—and see, in my own practice, how medications provide no real benefit (or, frequently, harm) compared with other treatments, I have to wonder whether we’ve gone WAY beyond what psychopharmacology can truly offer, and whether there’s any way to put some logic back into what we call psychiatric treatment.

Steve Balt is a psychiatrist who blogs at Thought Broadcast.

Image credit: Shutterstock.com

Comments are moderated before they are published. Please read the comment policy.

  • http://www.facebook.com/Cheryl.A.Handy Cheryl Handy

    I’ve been depressed. Medications helped me to a point that I could undergo behavioral therapy.

    Psychiatrists are a G*d send. We don’t have enough of them. Psychiatry changed my life. I respect the profession with all my heart. That being said, you are right about the lack of objective tests. Somedays you must feel like a veterinarian. My pup can’t explain his symptoms well either.

  • natalieg

    Hi – I agree with your view. You might already be aware of 2 books I’m reading on the very subject of the pharma approach to healing. “Unhinged: The trouble with psychiatry – a doctor’s revelations about a profession in crisis” by Daniel J. Carlat, MD; and “Daggers of the mind: Psychiatry and the myth of mental disease” by Gordon Warme, MD. As a psychotherapist, I don’t get to prescribe, nor would I want to. I do get to spend an hour (or more, if needed) listening to and responding to clients. I know some of my clients have used meds to help them cope, and I’m glad they exist. But as Warme says, it may be due to the placebo effect.

    • http://twitter.com/MsCrabass MsCrabass

      “Placebo effect”? I’ve spent 8 years trying to get off my SSRI due to PTSD (and evidently I was pre-disposed to anxiety and depression). I don’t even want to take an Advil. I hate being on my meds. I changed my diet, although I have always been a healthy eater, to add 10-12 ozs of green leafy vegetables in a blender. In a month I felt the best I ever have in all my life (this on top of an SSRI). So I figure ‘hey, I can finally stop taking the medication!”. That lasted 4 weeks and I went right back to my outward depression symptoms. I immediately went back onto the SSRI I’ve been trying for years to get off of. So “placebo effect” my arse.

      Turns out the added leafy greens to my diet just gave me an extra boost.

      I hate being on an anti-depressant. I use both a psychotherapist and a psychiatrist (who, btw, listens to me and asks questions for a good 30-45 minutes) and they collaborate with one another often due to my dx of chronic acute stress syndrome- the “PTSD” that never goes away, because I’m the mother of two medically-fragile, disabled twins.

      Placebo effect for some? Probably. For me? Not a chance.

      • Suzi Q 38

        Sometimes the drugs make you feel worse.
        Many make you feel numb or tired. Others cause weight gain.
        On top of other social and psychological problems, the side effects just add to the “mess.”

      • blehmeister

        Sounds more like an addiction

  • Dinah

    You’re doing something wrong. I’ve been in practice for 20 years, it’s unusual for people not to get “better,” whatever that might mean. Sometimes it take a while, sometimes it takes trials of different medications, and clearly not everyone gets “all better.” Psychiatric illnesses are episodic, and people will get better then get ill again (often because they seemed so much better that we all agreed it was reasonable to stop their medications…oops).

    I’m pretty convinced that medicines help a lot of people, but sometimes it is hard to sort out from life events getting better. I also think my optimism and belief in what I do is helpful — I tell people they will get better (especially if they have a history of recovering from past episodes) and often people tell me that my encouragement saw them through. And why would you see anyone for 15 minutes? It takes time to sort out the issues, and even if you pick the right pill, patients feel so much better if they feel their concerns have been heard and their psychiatrist really knows them, is on their side, and is plugging for their recovery. And the concurrent psychotherapy component is essential.

    I think you pessimism and skepticism about the medications is foiling you.

  • Jon Nixon

    A psychiatrist who can’t find time to ask his mood- disordered patients about their ongoing substance abuse is like an orthopedist who can’t find time to adress a broken bone. Do you really think” cocaine habit” ( strange you are gender specific) and “back pain” are of equal importance in a psychiatric interview?

  • http://www.facebook.com/johnckeymd John Key

    The great tragedy in psychiatry is its devolvement into “medication management” rather than comprehensive care. Sloppy diagnosis and polypharmacy also figure prominently in its [relative] lack of success.

    • DavidBehar

      The bemoaning of efficiency in psychiatry is just a hidden form of rent seeking to increase worthless make work and fees.

  • disqus_COuCUNP1V6

    Of course your medications don’t work – those are Skittles!

    • http://www.facebook.com/profile.php?id=100001331118070 Agun Yush

      I disagree, those are clearly smarties.

  • Markus Unread

    I had to rescue a friend who had self admitted to a psych ward at the local hospital. When I got her call for help, from the hospital, she was barely able to speak and was disoriented and hallucinating. I paid a visit to the hospital and after speaking with her, I was able to get hold of her chart. Her medication schedule had 13 drugs listed (in one 24 hour period). I took that list and checked with a friend who is a Psychopharmacologist. There were three different harmful drug interactions and two “not recommended” interactions among the 13 drugs. The next day, when I checked back at the hospital, my friend was suddenly on 5 meds (so much for ramping down the Lithium, Wellbutrin, Prozac and Thorazine). Evidently my poking around caused a re-evaluation of their over-the-top medication shotgunning.

    Before it was all over they had sent her home, alone and unsupervised, back on a number of drugs including Thorazine. The term non-functional was an understatement. I now see the need for education patient advocacy when dealing with the health care system, and that this applies doubly so when a psychiatric component is involved.

    • http://twitter.com/jmflahiff Janice_Flahiff

      Thank you, thank you for taking action here.

    • http://twitter.com/MsCrabass MsCrabass

      Sounds like she had a crap hospital, with crap psychiatrists. Not everyone experiences this. Small town, mid-west? Middle of nowhere?

      • Markus Unread

        Silicon Valley. I sure not everyone experiences this or MAJOR changes would be taking place.

  • f. lusu

    thank you dr. “interview, gut feeling and guess work-not biology” if mr.smith comes in and says he is depressed, he gets an anti depressant, or says he has panic attacks he gets xanax; maybe for a very long time. mr smith is doing so well on his medication that we are going to keep him on it. we keep mr smith coming back for his appointments because there is a financial incentive to do so. mr smith might even be put on an anti psychotic.just in case, because you never know, those mood changes of depression and anxiety might just be bipolar disorder; the diagnosis de jour. but mr smith seems to be doing so well on all the drugs that we are going to keep him on them. mr smith might have been doing well without the drugs because his situational depression and anxiety have abated with life style changes and therapy. a friend has told mr smith to check out his psychiatrist on the dollars for docs page. mr smith sees just how much money his psychiatrist is getting paid from big pharma. he figures out that it is in the drs best interest to rx those drugs.

  • http://twitter.com/jmflahiff Janice_Flahiff

    I stopped going to the psychiatrist because the 15 minute visits were only about how my meds were working. He was not interested in anything else, and I could tell, I believe, thru his body language. I just stopped taking the anti depressant and stopped going to the office visits..without consulting with him. Anyways, 4 years later the depression is still gone, to the best of my knowledge. I don’t believe it was a matter of cause/effect..but my depression lifted when I started working out, and strangely, after my position was abolished where I worked…

    Thinking there is a time/place for some psychiatric drugs, but some psychological disorders are, well, cultural/environmental…such as the high rate of depression in the US. So, I think at least some disorders are best addressed holistically and as public health issues….

    (Am not a health care professional…just lay thoughts!)

    • http://twitter.com/MsCrabass MsCrabass

      “Holistically” haha!!! As if.

    • DavidBehar

      Good for you. Now if family had brought you back, complaining you were in bed all day, plotting a suicide, you would need to get back on meds.

  • azmd

    As a psychiatrist, I am sad to see your obvious disillusionment with our specialty. I find that the vast majority of my patients do, in fact, improve with medication. Of course, I also spend a lot of time talking to them about their lives and the circumstances that have brought them into the hospital where I work. Talking to your patients and getting to know them as people is a critical part of the work we do.

    If you are really only able to spend 15 minutes with your patients, it’s not too surprising to hear that they are not getting better. What is a little surprising is that you are only able to give them 15 minutes when you have a cash-only private practice. On a cash-only basis, you should be able to structure your patient appointments more generously. Have you thought about getting some supervision from a colleague who has a more successful practice?

    • Docbart

      I agree. I am in a different medical field, but I give the patients the time they need. It is doable if one’s practice is optimized to stress quality and satisfaction, rather than income. Isn’t that ability to determine one’s own goals the reason to be in private practice?

    • DavidBehar

      This is an irresponsible viewpoint. There are long waiting lists of very impaired and dangerous people waiting to see a psychiatrist in most parts of the country, while you have your worthless chit chats.

      • azmd

        I make my living assessing dangerous people to determine whether they are safe to return to the community. How, exactly, do you think I make those determinations? I spend enough time with the patients so that they are comfortable talking to me honestly about their symptoms. It’s the only way to do it, and the fact that you think it could be done in 15 minutes just speaks to the fact that you don’t know anything about this sort of work.

        • DavidBehar

          I can’t believe you make such dangerous decisions based on the bs, and outright lies of criminals with such a vested interest in your report. You are also grandiose, thinking your quick relationship with criminals can be a reliable truth detector. During your extended evaluations, the criminals are scoping you out, and dishing you what you want to hear. While you were studying so hard, they were surviving the street. They have ten times your emotional intelligence and social skills. Worse, you are not even aware of this total disparity in persuasive power.

  • http://www.facebook.com/obinna.akunna Obinna Akunna

    Of course psych meds don’t work….and don’t even get me started on the side effects. Not sure how these things even make it past phase 1 trials.

    And the most annoying part is that treatment regimens are more art than science. Well that’s great if the original prescribing dr. stayed with the patient…..but these guys can go through four psych doctors in a year. You try figuring out why they don’t feel well when they are taking two anti-psychotics, cogentin, two or three mood stabilizers and of course an array of anti-depressants.

    I agree throw out the biochemical therapy till we know enough.

    • http://twitter.com/MsCrabass MsCrabass

      You’ve had a bad experience it seems. I’ve had no side effects from my current medication. Other than being annoyed by people like the author of this article and the people here who have nothing but bad experiences with psychiatry. Get better insurance.

      • http://www.facebook.com/Cheryl.A.Handy Cheryl Handy

        “Get better insurance”? Do you understand that a psych dx renders a patient uninsurable?

        • http://profiles.google.com/andeevb Andee Bateman

          not for long. PP-ACA is going to be a god-send for patients in this loop of uninsurability. Instead of ‘get better insurance’ the advice may change to ‘move to a exchange participating state’ but hopefully not for too long.

          • http://www.facebook.com/Cheryl.A.Handy Cheryl Handy

            It’s a bad idea to generalize. I am uninsurable (cancer, osteomyelitis, depression). I would rather forego healthcare than be apart of ObamaCare. And I will forego care for as long as I can.

          • http://autistscorner.blogspot.com Thalestris

            Hi, Cheryl.

            Can I ask why you would rather forgo healthcare altogether than get it through Obamacare?

            (I’m uninsurable, too, at least in pre-Obamacare terms, though I am very healthy and in great shape. Autism and depression.)

          • http://www.facebook.com/Cheryl.A.Handy Cheryl Handy

            ObamaCare is not the answer to the healthcare access problem. The federal government and a single payer system will destroy the delivery of medicine. For example, docs are leaving Medicare patients. Our country cannot afford ObamaCare. If I can’t get affordable private insurance or a direct pay system then I cannot get healthcare. It’s that simple.

            Since I am against ObamaCare, it would hypocritical for me to be a part of the system just because I have cancer.

    • Suzi Q 38

      I agree!

      My FIL was placed in a nursing home for about a year.

      I went to go see him and he was not his usual self.

      He was sleepy, lethargic, and not aware that we were there.

      I was angry. I knew someone gave him some meds without our authorization. I went to the nurses station and asked for any changes to his usual meds.

      The change was the addition of an average dose of Haloperidol….the problem was that he was in his 80′s, and this was not a low dose for him.

      When I asked why, the nurse said: “He was combative with a nurse this morning.”

      I told the nurse that I wanted the drug discontinued so that he could be more awake and I could ask him what happened.

      This took a day or two, and he awoke from his “stupor.”

      He said that he argued with a nurse because she was very rough and rude with him while helping him dress (stroke patient).

      He was aphasic, but he was competent.

      I called the nursing supervisor and explained the situation, removed the drug from his list, and asked that the nurse in question never be assigned to care for him. I pointed out that he had never had a problem at that facility with the other nurses.

      I also feel bad for the elderly. They are given drugs to keep them sleeping and easy to care for.

      I refused these types of drugs for my FIL.

      • http://www.facebook.com/Cheryl.A.Handy Cheryl Handy

        Sorry about your FIL.

        Putting the elderly on psych drugs is a frustrating reality. There are so many objective diseases that cause combative behavior – ie. upper UTIs in elderly often present with no other symptom than altered mental status. To save a buck, docs will order dip stick test instead of cultures. And, FILs suffer.

        My dad was combative after anesthesia. That’s typical for elderly.

        Drugging the elderly with serious psych drugs is ripe for another KevinMD article.

    • DavidBehar

      This is a totally irresponsible ipse dixit. Such irresponsible advocates including the author of the article, must held accountable for the 30,000 suicides and the 2,000 murders by paranoid schizophrenics.

  • buzzkillerjsmith

    Psychiatry is a scientific mess, no doubt, but I’m led to understand that brain physiology is somewhat complex. Give it time, decades maybe.

    In the meantime, you have to do something, doctor, even if that something is not much. At at least you know that the state of your field is, shall we say, suboptimal.. That’s a start.

    Remember your medical history. For most of its time our profession really had few cures or even good treatments to offer, but the patients came, and offer we did.

  • R Chahal

    As a fraternity we haven’t done a good job of delineating the etiologic basis of the problems of many of our patients. The criteria are too broad; however, the treatment is often just one: psychopharmacology. Or, at least, that is what we have been confined to. Whether it is because we have only 15 minutes med-checks or insurances would not cover any other treatment options.

    I was impressed when on my first inpatient psychiatric rotation, I saw a severely depressed patient respond to an SSRI, a floridly manic patient improve with Lithium, and a psychotic patient report he wasn’t hearing the voices anymore after being on an antipsychotic. Over the years; however, not all patients have been such. Majority are those who do not find medications working for them, or not like they would want them to. Often, misguided, they fail to report other vital factors that might be contributing to their problems. A diabetic usually doesn’t get good control over their blood sugars by just taking Metformin. So, how can we expect a depressed patient to get better with just antidepressants.

    Spending time with patients doesn’t just work in psychiatry, but I am pretty sure it does in any other specialty. We are just being kept from making use of the biggest treatment component.

  • Suzi Q 38

    I have had OCD (obsessive compulsive behavior) since I was about 8 years old. I have suffered from depression, anxiety and panic attacks for years.

    I have realized that a steady series of unfortunate personal events fueled my problems and exacerbated the above conditions. My parents were alcoholics and beat us every week. Enough said.

    I have never had medication.
    My psychotherapy has only been for 5 months when I was 12, and occasionally. Maybe one or two visits to a therapist every 15-20 years.

    My panic attacks stopped when I said to myself: “You are feeling a panic attack coming on…WHY??? What is scaring you? ”
    When I realized that it was public speaking, I decided to become a pharmaceutical sales rep and teacher. I forced myself to become what I feared. Guess what?? The panic attacks do not come anymore. They have not come for decades.

    Ditto for the anxiety and depression.
    I would do activities and only see people that were positive forces in my life. This meant that I had to distance myself from my immediate family, but this was good for me. I evaluate a friendship based on the positive and the negative effect it has on me.

    It took a lot of deliberate self assessment and problem solving.
    Mainly because psychotherapists are expensive, and when I was a young adult, I couldn’t afford it.

    Lucky me.

    My OCD??? I replace the hand washing ritual with using lotions instead.
    I still have to check to see if the garage door is closed after I already have left, but that does not make me late for work. The hoarding is a daily battle. I combatted this problem head-on by deliberately marrying a neat-freak 30 years ago. He constantly asks me if I really have to keep this or that.

    Now I am 56 years old and I have been happy for over 30 years.
    I just replaced my horrible family as a youngster with a beautiful one that I chose (husband) and helped create (2 children).
    I still see my mother and siblings, but at a safe distance logistically and socially.

    When your life is good, you don’t always need drugs to change it.

  • DavidBehar

    This left wing hand wringing by Dr. Balt is silly and ridiculous. The recommend course of antibiotics for a strep throat is to take them 10 days. After 5 days, patients feel better and stop them. This includes infectious diseases specialists with strep throat. No one is taking any medication unless symptoms are forcing them to.

  • StephenModesto

    ..I liked your post. I agree very much with your lead sentence, third paragraph. The very name of the field specialties of both psychology and psychiatry is the prefix `psyche’. This structure/process is identified but not often acknowledged. This is certainly non-empirical and it certainly is not merely bio-chemical `pathways’. The point(s) your raise, as an expression of your self-reflection are philosophical, is the phenomenology of that spiritualizing process with the consideration of Psyche. Depth psychology/psychiatry must be prepared, within the minds of the practitioners, to investigate those non-empirical parameters of that intrinsic quality of human life known perennially as Spirit….Your post seems to suggest that you preparing to initiate that path. Good for you and the patients you serve. Certainly a broken bone needs to be splinted as an intervention of care. The conversation about the situational behavior/circumstances of that fracture can come later, but encapsulating the neurochemistry of the brain/mind/psyche within a convenient plaster-cast of poly-pharamacy is neither an intervention of care.

  • Myrtle

    Medical evidence shows that the effectiveness of psychiatric medications is doubled when the patient receives psychotherapy. Mild to moderate depression and all anxiety is benefited more with therapy than with medications. The idea that meds can do all the work is not supported by medical evidence. It’s also not supported by logic. A person’s background, family of origin, life experiences, current life situation and relationships all influence their emotions and moods. A pill won’t change any of that. If this writer is in private practice, he shouldn’t bemoan the 15 minute follow up appointment. That is his choice and his alone. I won’t do med follow ups in less than 30 minutes, and that’s in a practice where every patient who sees the psychiatrist must also see a therapist. That is the most effective way to practice psychiatry. So you don’t get rich. Why be a doctor if providing effective care isn’t the most important part of the job?

Most Popular