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.


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.


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.


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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