April 13, 2009

How Dangerous Is Academic Psychiatry? Ask David Foster Wallace

No, not negligence, but nowhere near informed consent, either.

I've never read anything by David Foster Wallace, but I know he's got an intense readership.  I also know he ultimately killed himself after 30+ years (started when he was 16) of depression.  He had been on and off meds, many didn't work, and Nardil had managed to stabilize him for a while.

Then, this:

The New Yorker:

There were other important reasons to get off Nardil. The drug could create problems with his blood pressure, an increasing worry as he moved into middle age. In the spring of 2007, when he went to the Persian restaurant and left with severe stomach pains, the doctor who told him that Nardil might have interacted badly with his meal added that there were better options now--Nardil was "a dirty drug."
This passage-- especially the last two words-- stayed with me for a while.  I actually had a dream about it.  "Dirty drug."  I could hear the "psychopharmacologist" (that's apparently what the doc called himself) saying it.  

To me those two words symbolize everything that is wrong with psychiatry today.

I.

To a psychiatrist, "dirty" means the drug binds to what what makes it efficacious (e.g. serotonin receptors) but also a lot of other places that cause different side effects.  For example, Pamelor is a dirty drug because it binds to histamine (sleepiness) and alpha1  (orthostasis/lightheadedness), M1 (dry mouth, constipation), etc.  Prozac is an SSRI-- a selective serotonin reuptake inhibitor-- it does the one thing (serotonin) and nothing else.

No one says Prozac is more efficacious than a dirty drug, we say it has less side effects (sedation, constipation, etc.)

The problem is that there is no reason to make the distinction between effect and side effect.  I get that constipation and sleepiness are "bad," but how do you know the receptors H1, M1, and alpha1 are also working in some other way to generate efficacy?  Or that you don't need all of the receptors together with serotonin?  

The fact that we target serotonin for depression is a fact of marketing, not of science; thirty years ago we could have gone with dopamine reuptake inhibitors and bred a generation of Wellbutrin clones.  I'm not saying serotonin isn't relevant in some way; I'm saying when Abilify treats depression, don't assume it was serotonin.  Or the dopamine.  You simply don't know.

II.

My own observation: the words "dirty drug" are never preceded by the words "this is going to work awesomely because it's a."

As far as biases go, one could speculate that the more receptors it binds to, the better chance it has to work.  Right?  Why not?  But we have artificially chosen to believe the opposite.

The only time a psychiatrist would say "dirty drug" is when they're about to stop it.

Nardil caused a bad side effect for Wallace, and I can't fault the doctors for attempting a change.  But why say the words "dirty drug" to the family? 

He's saying it because he's a cowboy, an idiot, he's using the psych lingo to show he knows a lot about the drug-- "there are a hundred things wrong with the drug, no time to explain now, trust me, I know what I'm talking about."

The family is hanging on your every word, but because of the high emotionality they don't detect nuance.  They don't know what you really mean, and they don't ask because they think it's self-explanatory.

But psychiatrists love to use the lingo with patients, and no I have no idea why: dirty drug, augment, mood stabilizer.  Every time you use a psych term, even if it seems obvious, you are telling them something different than you think you are telling them.

III.

The article doesn't make clear who had heard the words "dirty drug" spoken.  Perhaps it is his wife, Karen Green; or it may have been his sister, Amy, who in another article seems to have finished the thought:

"So at that point," says his sister Amy, with an edge in her voice, it was determined, 'Oh, well, gosh, we've made so much pharmaceutical progress in the last two decades that I'm sure we can find something that can knock out that pesky depression without all these side effects.' They had no idea that it was the only thing that was keeping him alive." (emphasis mine, sarcasm hers.)

The doc said, "dirty drug."  Amy heard: "what kind of nut put David on such a dangerous drug?  Hello, it's 2008, we have way better drugs than that!  Thank God you came to us.  Nardil?  Are you f-ing kidding me?  What 1860s phrenologist came up with that?  Did he try exorcism, too?"

Do you think Amy had any confidence to try and  suggest that the Nardil be continued? 

Note the importance to Amy of this exchange. They were nervous about changing, and I'm sure the doctor gave his reasons why he thought a change would be beneficial.  But he then said "dirty drug" which conveyed incredulity and contempt.  That's not me speculating, that's Amy saying it.   That, my friends, is real undue influence.   This happens all the time.  If they had any reservations about changing the Nardil, that obliterated them.  As a family member, there is nothing you can say in defense of a drug that a doctor has casually dismissed as dirty.  

No doubt, it reinforced her guilt that she hadn't been doing the right thing for him; it reminded her of her stupidity, how could she not know Nardil was dirty?

I'm not saying I wouldn't have changed the Nardil (or that I would have).  But the family never had the chance to decide if Nardil was worth the risk, or not, because the doctor made it very obvious that it wasn't.

NB: he was wrong.

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Comments

How come when antidepressan... (Below threshold)

April 13, 2009 5:37 PM | Posted by acute_mania: | Reply

How come when antidepressants block a zillion different receptors, they're "dirty drugs", but when antipsychotics block things other than D2 receptors, they're "broad-spectrum psychotropic agents".

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@acute_mania: Same reason w... (Below threshold)

April 13, 2009 6:07 PM | Posted by mb: | Reply

@acute_mania: Same reason when a guy sleeps around he's a stud and when a girl does it she's a ho.

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wow. well-noticed and well-... (Below threshold)

April 13, 2009 6:18 PM | Posted by mmgutz: | Reply

wow. well-noticed and well-thought out. Wallace would appreciate your attention to the use of words; it's too bad that psychiatric narcissism prevented his doctors from maintaining the same.

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Reminds of a few years ago,... (Below threshold)

April 13, 2009 7:29 PM | Posted by Anonymous: | Reply

Reminds of a few years ago, in the hospital, again, and on something like amitriptyline, clonazepam, Seroquel, lithium and lamotrigine from a previous, and recent, hospitalization. My pdoc decided to include Celexa in the mix. "That should hit all the receptors," she said. I kid you not. I just wanted to bang my head on the table but I couldn't because of the straight jacket.

Ok, I was kidding about the straight jacket.

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Because a drug whose patent... (Below threshold)

April 13, 2009 7:34 PM | Posted, in reply to acute_mania's comment, by Anonymous: | Reply

Because a drug whose patent has expired is obviously dirty.

But a patented broad spectrum psychotropic agent, ooh la la. You know it's good just by the sound of it.

Who says receptors have to come into any of this?

Things just have to appear, they don't have to be.

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You owe it to yourself, con... (Below threshold)

April 13, 2009 7:48 PM | Posted by crumbskull: | Reply

You owe it to yourself, considering both your profession and your sense of humor, to at least read "The Depressed Person" and "Suicide As A Sort Of Present" from his collection "Brief Interviews With Hideous Men".

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The real problem here is th... (Below threshold)

April 13, 2009 8:01 PM | Posted by yoyo: | Reply

The real problem here is that the 'psychopharmacologist' is nothing of the sort. Adding an NRI would prevent hypertensive emergency, and MAOIs are good for people with essential hypertension. And, 'there are better drugs now' is bullshit, because MAOIs are the best antidepressants ever made. Sometimes i want to punch these idiots in the face; explaining to them things they already should know is far too good for them.

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Yeah, but hypertensive cris... (Below threshold)

April 13, 2009 9:05 PM | Posted by acute_mania: | Reply

Yeah, but hypertensive crises cause headaches, not stomachaches.

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Just a thought: people actu... (Below threshold)

April 14, 2009 1:46 AM | Posted by Anonymous: | Reply

Just a thought: people actually dealing with their emotions, other people letting them, meditation, healthy lifestyles etc etc... Jesus, whatever, milking the cows. (Although we have no cows here.) One of my favourite New Yorker cartoons: Man in front of medicine cabinet trying to decide on the right pill -- labels have tragedy and comedy masks. Theatre and ritual... (Not Hollywood and Broadway.)

An interesting side effect of reading your blog (which I enjoy) is that I wonder very seriously about this field. I'm just not convinced. The rhetoric, the meds, the pomposity of thinking one can have the measure of another... with the other not even capable of taking his/her own measure... I'm babbling.

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Or, the relatively recent r... (Below threshold)

April 14, 2009 7:15 AM | Posted by Dymphna: | Reply

Or, the relatively recent reformulation of Nardil may have added to his undoing:

(I won't paste the whole thing here... you can see my research at the link)

http://www.crazymeds.us/CrazyTalk/index.phps=&showtopic=5897&view=findpost&p=44760

d

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Let's try that link again..... (Below threshold)

April 14, 2009 7:16 AM | Posted by Dymphna: | Reply

Let's try that link again...

http://www.crazymeds.us/CrazyTalk/index.php?s=&showtopic=5897&view=findpost&p=44760

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Active placebo. A placebo w... (Below threshold)

April 14, 2009 8:52 AM | Posted by Anonymous: | Reply

Active placebo. A placebo with a noticeable physical effect boosts the placebo effect.
Are psychiatrists now neurologists ? No one told me.
Tell me about the serotonin lab test results?

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By the way, has anyone look... (Below threshold)

April 14, 2009 9:22 AM | Posted by Anonymous: | Reply

By the way, has anyone looked into Prozac's receptor binding profile? I don't quite understand what makes Prozac a "clean" drug when it binds to a zillion things other than the serotonin transporter. Oh, yes I do: "Clean" drugs are easier to market, right? That is until Effexor comes, and then you start making the argument that hitting more than one receptor system is actually better for you.

I just wonder why there is so little accountability in my field.

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He's saying it because h... (Below threshold)

April 14, 2009 11:48 AM | Posted by Joseph Bergevin: | Reply

He's saying it because he's a cowboy, an idiot, he's using the psych lingo to show he knows a lot about the drug-- "there are a hundred things wrong with the drug, no time to explain now, trust me, I know what I'm talking about."

This happens in every field, apparently. Ask an average IT person if Windows Firewall is a useful security measure, and you'll get a similar dismissal ("Everyone knows it's garbage.") without elaboration (or with erroneous elaboration). MAOIs and Microsoft products are both maligned unfairly.

IT people are also similarly (inordinately, really) fond of using lingo to demonstrate the span and currency of their knowledge. Though there haven't been any fundamentally new technologies introduced in the last few decades, there are plenty of new terms that make it seem like there have been. Once everyone is familiar with the new terms, they lose their power of obfuscation and are discarded.


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Weird how this readership s... (Below threshold)

April 14, 2009 2:26 PM | Posted by G. Day: | Reply

Weird how this readership seems to intersect so strongly with Wallace's. And when I say weird I mean "not weird at all, because some of the points you try to make are similar".

I don't know if you can really call this anything less than uninformed consent. Reading through Infinite Jest, you find a lot of references to pharmacology; maybe he wasn't an expert, but he was degrees of magnitude more informed than your typical rube. He wanted to get off Nardil, all he was looking for was permission. He even tried to get back on it, after the other drugs proved, uh, inefficacious, but apparently going off and then back on to an anti-depressant doesn't work every time. (Why is that?)

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Weird how this readership s... (Below threshold)

April 14, 2009 2:27 PM | Posted by G. Day: | Reply

Weird how this readership seems to intersect so strongly with Wallace's. And when I say weird I mean "not weird at all, because some of the points you try to make are similar".

I don't know if you can really call this anything less than uninformed consent. Reading through Infinite Jest, you find a lot of references to pharmacology; maybe he wasn't an expert, but he was degrees of magnitude more informed than your typical rube. He wanted to get off Nardil, all he was looking for was permission. He even tried to get back on it, after the other drugs proved, uh, inefficacious, but apparently going off and then back on to an anti-depressant doesn't work every time. (Why is that?)

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Viagra is the dirtiest drug... (Below threshold)

April 14, 2009 9:52 PM | Posted by John: | Reply

Viagra is the dirtiest drug of all, nay, perhaps that goes to Valtrex.

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This is pure speculation: P... (Below threshold)

April 14, 2009 10:01 PM | Posted, in reply to G. Day's comment, by Anonymous: | Reply

This is pure speculation: Preventing a depressive episode by acting on a "non-depressed" brain may involve some degree of distinct neurocircuitry/neurochemistry than what is modified by an antidepressant while the individual recovers from depression. Given how the environment, metabolism, and human brain change over time, it is plausible that a drug that was able to work for both tasks may lose its ability to accomplish one.

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acute-mania:PROBABLY... (Below threshold)

April 15, 2009 4:05 AM | Posted by Anon: | Reply

acute-mania:
PROBABLY HAS TO DO WITH BRANDED TRENDY DRUGS BEING MORE EFFICACIOUS.

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But psychiatrists ... (Below threshold)

April 15, 2009 7:27 AM | Posted by Kevin: | Reply

But psychiatrists love to use the lingo with patients, and no I have no idea why: dirty drug, augment, mood stabilizer.

What would you use in lieu of augment? "Helper drug?" I just never thought of "augment" as being psychiatric lingo. And what about mood stabilizer? Do you, instead, describe medications by their receptor activities?

Seriously, as a (soon to graduate) resident, I'd be interested to hear suggestions on how to communicate pharmacologic information to patients. I do realize that we've been our bubbles for so long that many of us forget how to talk in lay terms. I just always thought that I was good at communicating with patients, but I have to admit that I've used all three of those terms.

(I try to gauge my patients' educational level, and then adjust accordingly, but of course you're sometimes going to over- or underestimate a bit. Some are offended if you talk down to them, some come to their first appointment spewing more psycho-lingo than I even know, others wants me to break it down kindergarten-style. I'm happy to do any of the above, but people have to understand that despite best efforts, we're going to often miss the mark, especially during initial interactions with them.)

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doesn't every profession lo... (Below threshold)

April 15, 2009 12:41 PM | Posted by daniel: | Reply

doesn't every profession love to use its lingo when dealing with clients?

You seem to advocate the evisceration of jaron generally. This is fair, jargon is foten confusing to the uninitiated but doesn't jargon also serve efficiency purposes.

Jargon is kind of like an established trademark: a way of communicating a lot of infromation in a concise way, between professionals, and a way of establishing authority, between professionals and their clients. It shows that you are familiar and comfortable with the conventions of the profession and many people may even feel MORE comfortable with a jargon-using professional than with one that uses lay terms.

In this case jargon is BAD because he was wrong. If DFW had instead gone on to recover and write a bunch of awesome books the same jargon-spewing professional may have been lauded. At least by david and his family.

Sure there is a kind of "bargaining power problem" between a psychiatirst and his patient as the patient has no real way to question his psych's decisions but patients can also go for a second opinion. And what's the point of going to a doctor if you aren't going to trust his authority? How many patients want to know the difference between drug x and drug y and how they work? Or can understand it.

Arguably, this is an especially important profession and thus should be subject to stricter regulations of jargon use. But how do we tell which professions can use jargon and which can't, when they can and can't, whith whom they can and can't. It's a line drawing problem and i think that the overall efficiency of jargon will probably outweigh the benefits of its destruction.

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It's a line drawing prob... (Below threshold)

April 15, 2009 5:27 PM | Posted, in reply to daniel's comment, by Eddie Sylvano: | Reply

It's a line drawing problem and i think that the overall efficiency of jargon will probably outweigh the benefits of its destruction

I agree with your assessment of jargon as economical, but it does assume that it's also informative. Our host's love of Wittgenstein would indicate that he sees jargon, particularly more abstract jargon, as intellectual laziness. In Wittgenstein's world, language is only valuable for discrete "propositions," which relate a logical relation between "states of affairs." In this light, most language is subjective blather with no demonstrable truth.

Jargon is dangerous in that it serves as an artificial endpoint to understanding. The technical nature of jargon is mistaken as a sort of gravity and truth beyond more familiar vernacular. "Dirty drug" is a nonspecific descriptor that can be interpreted freely. The "drug" part is fine, but dirty is subjective. To the uninitiated, drugs are a mystery anyway, so to hear that one is "dirty" doesn't add anything to understanding, and doesn't invite inquiry for those cowed by the professional. They're free to imagine a myriad of things that make it dirty, and do. Dirty is their starting point and anchor.

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"In Wittgenstein's world, l... (Below threshold)

April 16, 2009 1:27 AM | Posted, in reply to Eddie Sylvano's comment, by PI: | Reply

"In Wittgenstein's world, language is only valuable for discrete "propositions," which relate a logical relation between "states of affairs." In this light, most language is subjective blather with no demonstrable truth."

What?

http://en.wikipedia.org/wiki/Philosophical_investigations#Language.2C_meaning.2C_and_use

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I can see your point but th... (Below threshold)

April 16, 2009 4:22 PM | Posted by daniel: | Reply

I can see your point but that seems applicable mainly to this special case.

What we term things will always influence how others think about them. There is a huge difference in the onlookers perception between one who is "shell-shocked" and one who has "PTSD". We use the latter term and not the former for a reason.

The reason is an attempt to change how other percieve the sufferer and how he percieves himself. I don't know who this benefits, it may be just re-arranging chairs, but i would think this benefits the suferer at least to some degree.

At the very least people put a lot of "stock" in what we name stuff. I can say black person but i can't say nigger.

Finally, "dirty drug" may be a poorly thought out moniker when we look at how outsiders will percieve the advice the professional is giving but i think this may be just a function of the word "dirty" and is a simple enough problem to fix without eviscerating jargon.

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I'm not against jargon; ... (Below threshold)

April 20, 2009 10:01 PM | Posted, in reply to Kevin's comment, by Alone: | Reply

I'm not against jargon; I'm against confusing people. When Jack Bauer on 24 says, "Engage! Engage!" that's jargon-- he means shoot them. But if there was a possibility that I would think he meant "marry them! marry them!" then he shouldn't use it _with me._

Sometimes jargon is meant to exclude the uninitiated-- fine. But to use it when it could easily be misinterpreted... when more accessible words would do.. see? Also, the pharmacologist used the jargon-- let's face it-- in order to impress. (Yes, it's speculation on my part.)

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What's really sad is that m... (Below threshold)

May 4, 2009 7:00 AM | Posted by Anonymous: | Reply

What's really sad is that mood stabilizer and dirty drug is psychiatric lingo, I'm sure these terms started out as terms used to dumb things down for patients, but they've come to be used as convenient cliches that only have meaning to psychiatrists.

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As the March 9, 2009 New Yo... (Below threshold)

June 21, 2009 4:54 PM | Posted by Altostrata: | Reply

As the March 9, 2009 New Yorker profile by D. T. Max makes clear, before David Foster Wallace's death there was a trail of the usual psychiatric misinformation and cluelessness, including that 3 minutes of consultation led to 22 years of Nardil prescription.

The conclusion that Wallace died because Nardil was keeping him alive is erroneous. Withdrawal of Nardil did not cause relapse of his depression -- it caused obvious antidepressant withdrawal syndrome.

Wallace hung himself after more than a year of antidepressant withdrawal syndrome. The symptoms can be unbearable; see patient reports at http://www.paxilprogress.org/forums/showthread.php?t=20079. The rest of the site contains hundreds of heartbreaking stories about this iatrogenic condition.

Prolonged antidepressant withdrawal syndrome is almost always ignored, misdiagnosed, and mistreated by psychiatry.

Wallace suspected additional drugs were making him worse, and he probably was right. That's very common in withdrawal syndrome. Some patients become hypersensitive and prone to paradoxical reactions from any neurologically active medications or even vitamins.

Who wouldn't reasonably consider suicide if told he had a new, virulent, and apparently untreatable form of mental
illness?

I should know, I've had Paxil withdrawal syndrome for more than 4 years. 18 months ago, when I completely lost the ability to sleep because of it, I would have killed myself except that in the nick of time I found the one doctor in the world who can treat it, right here in San Francisco.

Disruption of sleep architecture is very common in antidepressant withdrawal syndrome, as is emotional blunting. (Heath Ledger died of self-medicating intractable insomnia after Zoloft withdrawal.)

The precipitating factor was not an inaccurate remark about a "dirty drug" (it's a fantasy that any of them are "clean"). Wallace was well-read about the drugs. He had suffered years of side effects. His life had progressed. His reasons for stopping Nardil made sense. But he was not prepared for withdrawal syndrome.

Wallace's death haunts me. If he had only known he had withdrawal syndrome, not an untreatable soul-killing relapse, and he would probably slowly recover from it....

Yes, academic psychiatry is dangerous. It has deliberately suppressed information about antid