Saturday, July 14, 2012

Those Lying Psychiatrists

In the comment section of some of our blog posts, there have been comments about psychiatrists who lie.  While I haven't kept a tally of these remarks,  I think the most common assertion is that psychiatrists lie by telling patients they have to remain on medication for the rest of their lives.

My understanding of the term verb "to lie" is that it requires the person who utters a communication to know that it is not true, and it often is accompanied by a deceptive motive.  So, for example, if a patient has a UTI that can be treated with a cheap antibiotic taken for three days and the doctor knows this, but he is getting a kickback from the pharmaceutical agency and he's having trouble filling his schedule, so he prescribes the expensive antibiotic and tells the patient "You must remain on this for life, and you should come in for weekly visits or you will most certainly die," then this is a lie.

In medicine, we know very little for sure.  Every now and then we do know something absolute, like that if you do nothing about a specific condition, you will die.  What doesn't get said is that even if you do something about it, you may still die, and that no matter what, eventually you will die.

Doctors seldom know that you must do anything, when they say you must, or you should, or you need to, they are making a suggestion or recommendation based on the evidence that is available.  It's rare that evidence is complete.  You need to remain on this psychiatric medication for life is not any different in my book then You need to remain on a statin for life, or a blood pressure medication, or aspirin.  Maybe you have risk factors for coronary artery disease but it's possible you could live out your life without a statin without having cardiovascular disease, in which case you didn't "need" the statin.  Was your primary care doctor lying?  Of course, in the meantime, the statin could give you muscle problems, cause diabetes, or increase your risk of death by other means.  Oh, and while we're here, you "need a pap smear every year."  Oh, except now it's every 2 or 3 years, and not after 65.  Does every woman over 40 "need a mammogram?" Maybe it's 50?  Depends which agency you ask.  And don't start me on calcium, vitamin D supplements, yearly PSA measurements,  hormone replacement therapy, biphosphonates and all the other things we're told we "need" until it turns out they kill us. (Please note, there is nothing that currently indicates that vitamin D kills you and calcium only gives you increased risk for kidney stones, it doesn't kill you, and biphosphonates don't kill you unless perhaps they give you esophageal cancer).

When a patient is told they "need" a psychiatric medication for life, it's because the doctor believes the risk is high that the psychiatric disorder will recur without it.  Sometimes, it seems like a fair bet or that the risks are too high to chance NOT staying on a medicine.  Seven episodes of disabling major depression that caused the patient to lose their jobs, spouse, and have 4 hospitalizations and 3 serious suicide attempts?  Might not be a bad idea to stay on those meds, and you might not need such an extreme example to get there (I like to stay away from the lines).  

Sometimes, we're wrong -- after all, the recommendations are based on studies and statistics from groups of people with symptoms or illnesses, not on individuals.  The truth is that for most of these things, you don't know for sure until you try stopping them and see how you do without them.  But to call the doctor a Liar?  Isn't that going a bit far? Might be better to consult a fortune teller rather than a physician.


George Dawson, MD, DFAPA said...

Great observations. Part of the problem is the way that medicine is politicized - largely to create a sensational atmosphere to to sell newspapers, books, TV time, etc. I think that is part of the reason why you hear about calcium and Vitamin D replacement right up to the point something else becomes fashionable. BTW - the Vitamin D problem is a classic example of how much we don't know. I have a very expensive two volume set of books on Vitamin D and there is still no consensus on what the daily requirement is.

The other common rhetorical device is the myth of the ideal medication. You know - the one with no side effects or serious adverse effects. It seems that nobody stops for a moment to think that at a certain point in time most people (including psychiatrists) have to make a decision about whether to take a medication and whether it is worth the bother. Unless you are incredible lucky - it is all part of being human. There is nobody I have ever heard of who wants to take medication. The strongest endorsement I usually hear is: "What else are you going to do?".

Psychiatrists can only advise people on their best recommendation. It is clear from the literature that many people choose not to accept that advice. I think it would be foolish to tell a person that they need to take a medication "for the rest of their life" because there is very little evidence that would occur.

Amy said...

perhaps rather then taking the view that the solution is for patients to stop calling their psychiatrists Liasr, the effective response might be to train psychiatrists to add in a few words "I think" or "In my experience," or "It's impossible to know the future, but,"......

Then again, that might risk those dear psychiatric egos, to speak to their patients as human beings, to acknowledge that yes, a lifetime on psychiatric drugs is scary and sad, even if a best bet.

(disclaimer: I have been lucky to only ever have psychiatrists who did reply along those lines - It's impossible to know for sure, but... I think.... Because of x, y, and z it seems like.... so I am not taking opposition to shrinks in general, but your general tone and perspective.)

Anonymous said...

Doctors can be so very arrogant to the point that imho is not something they would say. They may lie about meds when in reality they ought to say it may be a good idea for now and let's reassess down the line. More often, shrinks lie about more than just meds. Yes, many of them are LIARS.

Anonymous said...

Read it. Everybody lies.Admitting it is a good first step.

Dinah said...

George: Agreed.
Amy: Those are really good ways of communicating.
Anon: I agree about 'good idea for now and let's reassess later' (my personal approach to most situations)--I still think that many docs who tell patients they need a medicine forever may saying it because they believe it's in the patient's best interest.
Last anon: Thanks for the link-- it's a good article.

Steven C. said...

I think it would be odd to categorize all Psychiatrists as liars in any situation. Of course, there are many Psychiatrists who lie - and they are really bad! But I agree, and hope, that most Dr's are not liars and have their patient's best interest & health in mind.

On a slightly personal note, I am not a professional by any means and benefit much from the field, so I remain open to the support and growth offered by it. However, I also work very hard and pay lots, and lots, of money for healthcare. So I can understand, and tend to side with the patient's perspective. At least in private practices anyway - a reason why "lying" is a non-issue when it comes to my own mental healthcare.

Anonymous said...

Here is some help for doctors in deciding when to lie.
For what it is worth, lying is deception "for some motive" even if the doctor is not receiving a financial kickback.Sometimes the doc just does not want or know how to deal with the patient, so they lie. To speak of lying with deceptive motive is redundant. Lying is deception. You can choose when or if you believe deceiving a patient is something you want to do. If, for example, you believe that telling the patient they need Med X forever will result in higher compliance, you may choose to lie. As you have read, the patient, may choose whether or not to believe your lie (it is a lie if you do tell someone you know something with a certainty that you cannot possess). Should the patient choose not to believe your lie and at the same time understand that he or she is being deceived or manipulated, they will often make the choice to lie to you.

I felt it best to lie to my spouse about an affair. It would only have hurt my spouse. I did my spouse a favor by protecting their feelings. I am so thoughtful

Jane said...

I read your racket article and I would think that prescribing psych meds in primary care is even more of a racket. They don't offer anymore than psychiatrists and probably even offer less in a lot of cases.

Quick story: Asked the new primary care doc during a visit if he manages psych meds. He said yes. I think to myself that I can eventually come down and ask him to manage my meds. Fast forward to a meeting I have with his NP.They will manage meds, BUT THEY WON'T DO MED CHANGES???!!!

Okay, honestly...if you don't do med changes...that means you don't manage psych meds. At least that is what that means in my mind.

I don't even know why someone would manage meds if he or she didn't feel comfortable doing a med change. I could see a lot of things going wrong with that quickly.

Jane said...

...and I just realized I posted that comment under the wrong article. Oops. Oh well.

William said...
This comment has been removed by the author.
William said...

Precisely the reason why, as a psychiatrist, I never say to a patient: "you NEED to stay on this medication for the rest of your life." That statement is scientifically unsupportable and I can't back it up.

I have said the words: "your illness is believed to be chronic and, if you stop treatment, it is my expectation you will suffer a relapse, which will likely be even harder to treat. So I strongly recommend you continue treatment indefinitely."

THAT is a statement I can back up.

Anonymous said...

I had a psychiatrist tell me that I would have to take medication for the rest of my life, that ECT was the only option left for me, etc. While I wouldn't characterize the physician as a liar, I don't think those kinds of dire predictions were helpful and in fact only left me feeling more hopeless and despondent. Well intentioned, perhaps, but helpful? No. I don't see that psychiatrist any more because I don't care for that kind of approach.

Unlike my previous psychiatrist, the psychiatrist I have now is not paternalistic and has made no dire predictions that my life will be over if I don't do what he recommends, that I require ECT to survive another day, or that I must be on meds for the rest of my life. He offers me his opinion, I share any thoughts or concerns I have, and we work together. Many times I decide the risk/benefits are worth what he recommends, sometimes I decide they're not - my choice. This is also the type of relationship I have with my PCP and other physicians I work with, as well. I don't expect physicians to know everything, and I'm most appreciative that most physicians I've worked with don't pretend to.

Kamalks said...

Anonymous said...

Psychiatrist are extreme liars. It is very concerning when those who the mentally unstable is the most unstable of all. They lie on peoples records to involuntary commit them into hospitals. They state things that are so far from the actual truth. Everything must be quite surreal for those who are already dealing with mental disease. It is very improper for a patient to be abuse mentally under the care of his/her doctor who is professing to be giving him care. They are the most unintelligent group due to their repetitive questioning and lies conceive. There is not much to psychology but patients being led to trust in those who do not care one bit about their care. I am even shock by what psychiatry call therapy. It's unbelievable. They do nothing, absolutely nothing but prescribe pills.

Anonymous said...

How do I count the ways? Well, when you have a profession that officially believes in no notable ethics of any kind, then lies are fine. E. Fuller Torrey acknowledges the lying yet contends this is necessary and beneficial. Falsify records? Check. Engage in hyperbole of patients for insurance purposes? Check. Destroy the patients' lives with labels? Double and Triple Check. Ignore state mental health laws in involuntary commitments? Check. Ignore the Constitution and due process in such processes for all patients? Check. Dr. Szasz had it right:words from Psychiatrists might as well be "blackjacks", because the patient is always harmed by a profession based on false premises, insufficient sience, and inappropriately uses language analogous to medical problems but these do not represent medical problems. The biggest medical problem is Psychiatrists. Period.