Psychiatrists give their patients all kinds of drugs, but in most cases, they do so without ever taking any themselves. Some French psychiatrists found an excuse to try out some drugs in the name of science, and the results are published in a paper just out - Besnier et al's Effects of paroxetine on emotional functioning and treatment awareness.Thirty healthy psychiatrists and clinical psychologists took paroxetine 20mg per day, or placebo pills, for 4 weeks. Paroxetine (Paxil, Seroxat) is a popular SSRI antidepressant - popular with doctors, at least. It has a bad reputation amongst users as causing serious withdrawl symptoms, even compared to other SSRIs. These psychiatrists decided to wean themselves off with a week at a reduced dose of 10mg before stopping completely - after just one month on it! Make of that what you will.
Anyway, what happened? The participants experienced no changes in mood or anxiety, although since they weren't depressed or anxious to begin with, this is not surprising. However, the people taking paroxetine did report reduced "Internal Emotional Experience" as measured with the Emotional State Questionnaire (designed by the same people who ran this study.) That means they were less likely to answer yes to questions like “Do you feel anger when faced with a familiar face with expressed anger?”
This sounds as though they experienced the "emotional blunting" reported by some people who take SSRIs, although it's not clear what exactly this questionnaire is measuring, or how powerful the effect was. The paroxetine group also reported feeling sedated and suffered many more side effects - 70% of participants presented with an adverse event for more than 3 weeks, vs 20% of placebo.
Most described adverse events were psychiatric (sleepiness disorders, libido decreased), gastrointestinal (nausea, diarrhea), or neurological signs (headache).There's a twist, though, in that while 20 of the subjects got placebo or paroxetine in a double-blind manner (10 each), the other 10 got paroxetine unblinded, i.e. they knew they were not going to get placebo. Strangely, the unblinded group experienced much weaker effects than the double-blind paroxetine group, including many fewer side effects. What's up with that? It's hard to say. It doesn't make much sense. To be honest, with just 10 people in each group, any or all of these results could be random chance anyway.
Still, I do like the idea of psychiatrists self-experimenting. Sadly we're not told whether they were more or less likely to prescribe paroxetine after taking it themselves! Still, I have a bit of anecdotal evidence here. I was talking to a French psychiatrist a while ago who said he'd self-prescribed the SSRI antidepressant citalopram and thought it was brilliant. But one day he accidentally picked up a box of chlorpromazine instead (they were next to each other on the shelf) and that wasn't much fun at all...
Freudian psychoanalysis requires trainee therapists to undergo a full course of therapy themselves before they get to inflict it on their patients. Maybe psychiatrists should have to take courses of antidepressants and antipsychotics as part of their training? Or as the psychopathic bounty hunter said to the doctor in Joss Whedon's Firefly -
Jubal Early: You ever been shot?
Dr Simon Tam: No.
Jubal Early: You oughta be shot. Or stabbed. Lose a leg. To be a surgeon, you know? Know what kind of pain you're dealing with. They make psychiatrists get psychoanalyzed before they can get certified, but they don't make a surgeon get cut on. That seem right to you?
- Firefly
Besnier N, Cassé-Perrot C, Jouve E, Nguyen N, Lançon C, Falissard B, & Blin O (2009). Effects of paroxetine on emotional functioning and treatment awareness: a 4-week randomized placebo-controlled study in healthy clinicians. Psychopharmacology PMID: 19826792
30 comments:
Plato said that to be a good physician knowledge is not enough. You have to suffer in first person the sickness of disease.
Wow, they took paxil for a month. That totally mimicks the real world experience of the average psych patient... NOT.
Anonymous - Point taken. Although the great majority of people who take antidepressants only take them for a month or less...
I wonder how many of them would gave been willing to take Zyprexa for even a month? I would have loved to see if they had more sympathy for patients' troubles w weight gain if they had been on that or Lithium or Depakote for 3 months at a typical dose. Those drugs were prescribed to a desperately ill kid in my family (skinny before) and caused massive weight gain, torpor without helping the target symptoms. Likewise, a person needs to be on SSRIs at least 3 months to experience the blunting. This reflects the short testing period for drugs. But good for the French shrinks anyway.
If a psychiatrist took drugs for a month and they made him mad...how could anyone tell?
It has been my understanding, that the patient is the one with the disease. It's odd to demand a psychiatrist to take medications and Plato was not a doctor after all.
I don't expect anyone to fault an endocrinologist for not taking insulin for a month or an oncologist for not treating self with vincristine. Why such a brazen demand on psychiatrists?
BTW, many psychiatrists do take meds and many treat members of their families. In fact more so than endocrinologists, oncologists, and surgeons.
An afterthought:
Psychoanalysts spend years in therapy precisely because psychoanalysis is at best useless for treatment of mental disorders. Freudian psychoanalysts deliberately obfuscate differences between health and sickness to advance their cause.
Usefulness of any intervention for diseases might be fairly judged by its power to change.
Purely as a matter of interest, are you this Michael Levin?
http://home.earthlink.net/~mishal/
Michael: I've got no fondness for Freud, see e.g. this post. And psychoanalysis certainly does blur the distinction between health and illness. However, putting therapists through therapy is one way of making them understand its complexities...
You say "I don't expect anyone to fault an endocrinologist for not taking insulin for a month", neither do I, but I would fault an endocrinologist who hadn't read the scientific literature on insulin.
Now of course there's a literature to read about psychiatric drugs too. But the difference between psychiatric drugs and insulin is that insulin treats a purely physiological problem and it has purely physiological effects, so reading about it is the best way to learn about it.
By contrast the symptoms of mental illness and the therapeutic effects of psych drugs are psychological (whatever the underlying biological basis might be). So I don't think you can fully understand them just by reading about them or observing their effects in others.
For example SSRIs cause "emotional blunting", at least according to some things you'll read. But those two words "emotional blunting" completely fail to capture the nature of the effect. arguably the only way to know what it's like is to experience it for yourself.
Now "emotional blunting" could be a good thing or a bad thing for any individual patient, sometimes it might be very useful (I found it helpful when I started on citalopram) but it's something that psychiatrists should be aware of. And I'm not sure there's any good way to understand it except through personal experience. You could talk to your patients, but, they would have to be very articulate, and have a lot of time on their hands.
I agree this may be helpful with certain medications, but taking a drug is probably provides a fairly limited understanding in many ways. First, there is so much variability in how the individual responds to a certain drug that there could be a danger of overgeneralizing ones own experience. Second, the effect of a drug may be much different for someone displaying the symptoms it's intended to treat than for someone without those symptoms. For example, as I understand it (and have observed to some degree), amphetamines have a much different effect on someone with ADD characteristics than they do on someone without.
Neuroskeptic,
I think that close approximation to what patients are experiencing with medications can be achieved through intelligence, experience, and empathy without drastic measures. I might suggest that young physicians shadow experienced psychopharmacologists for a couple of years, similar to psychoanalysts bringing cases and undergoing supervision with senior therapists.
I also agree with BrianW that personal experience with meds might be incomplete and even misleading.
Present classification of mental disorders and terminology are in disarray. The field begs for new paradigm. I imagine that it looked like insurmountable task to classify medical disorders two centuries ago but it happened.
Neuroskeptic,
As one who is slowly tapering off of psych meds due to a hearing loss and cognitive issues, I think this issue is important. Thank you for posting this.
While I am glad this study was done, I don't think 4 weeks is long enough to draw any conclusions on withdrawal symptoms. The brain starts making neurochemical changes at that point in response to the psych meds.
That is why people who have been on the meds for up to 4 weeks can taper usually pretty quickly without problems compared to the person like myself who has been on them for years. By the way, I disagree vehemently with your assessment that people take these drugs for a short time only.
Anyway, I think a more valid study would be if these doctors were on these meds for 6 months. But I think they know what the deal is and probably deliberately kept the time period to 4 weeks.
Dr. Levin, you're missing the point about this issue. I wish I had a nickle for every person who has complained about side effects and withdrawal symptoms to their psychiatrist only to be told they were imagining things and it was a worsening of their illness.
Some people who got that speech were put on psych meds for for non psych issues.
It seems like psychiatrists were taught in medical school to blame all med reactions on the patient. I am not saying all of them are like that but it sure seems like alot of them are.
That is why people like me would love for these folks to be on these meds for a minimum of 6 months and then try to come off of them. We wonder if their attitude would change.
But Brian may be right about it not making a difference.
AA
Anonymous, I completely agree with you.
Anonymous,
Let me make my point clear. I never argued that psychiatric medications side effects are patients fault (nowhere you'll find that in my posts) but that doctors are poorly trained to administer the meds.
One of the reasons is faulty classification designed with psychoanalytical model in mind and not suitable for modern psychopharmacology.
By analogy, imagine treating diseases with modern antibiotics using traditional chinese medicine model (meridians, qi, jing, ying and yang, etc.)
I advocate education of populace and physicians and development of better meds, instead of forcing doctors to take medications they don't need. From practical point of view, how do you plan to enforce it in democratic society?
Saw this on TWIM.
"Strangely, the unblinded group experienced much weaker effects than the double-blind paroxetine group"
My thoughts on this is the unblinded psychs were probably trying to minimise the side-effects as they think paroxetine is a good thing! A false-placebo effect almost.
Also must add - anyone that includes firefly quotes in blog posts is clearly great!
intothesystem - Thanks! Nice idea re: minimizing the side effects, I hadn't thought of that. However, I'd have thought the double-blind people would have been equally likely to do that, because they knew they were getting paroxetine if they were getting anything, and they knew to expect typical SSRI side effects, so they could just avoid admitting to those...
"don't expect anyone to fault an endocrinologist for not taking insulin for a month or an oncologist for not treating self with vincristine. Why such a brazen demand on psychiatrists?"
I can see where you're coming from with this Mike, and while I don't think it should be mandatory for psychiatrists to trial psychotropic drugs they prescribe, I do think we should remember that an endocrinologist does not force an individual to take medication they don't want. (I admit there are some occasions in which they may act in a patients best interests. A coma patient for example). An individual may decline to take a particular medication and the endocrinologist has to live with that decision. The is in contrast to the psychiatrist, who does have the power (and is expected to use it by the state...harm to self/others) when they deem it necessary, to force medication on individuals whom refuse to take it.
Paul,
If you advocate better training of physicians and ethical administration of psychiatric medications, I am with you all the way. Most prescribers (psychiatrists, primary care, or other specialists) have vague understanding about role and effect of psych medications. Making them take the meds won't advance the knowledge, however. Not sure about ethics, either.
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While I have no problems with psychiatrists drugging themselves and reporting the effects, I don't think it should be mandatory, or even strongly encouraged.
And the reason is, bias. I'm sure nobody will argue that drugs have the same effect on everybody, and considering that there is no positive gain to be gotten by drugging a perfectly healthy person, do we really want to risk psychiatrists becoming arbitrarily and strongly biased to one particular drug simply because they had a bad experience? IMHO, there's better way's to create a sympathetic doctor.
Plato said that to be a good physician knowledge is not enough. You have to suffer in first person the sickness of disease.
Lot of truth to that. Nothing like first hand experience.
Present classification of mental disorders and terminology are in disarray. The field begs for new paradigm.
Or being completely disbanded.
(I exaggerate for effect, but not that much. At the very least psychiatry's bailiwick needs to be seriously curtailed until they can come up with far more rigourous and reliable diagnostic and therapeutic protocols. Until then they have no right to claim the degree of 'science based' authority they currently do. As it stands, they are guessing as much as anything, and as always, it is patients who pay the price for it.)
I'll admit, there have been times when I've wished a month of Clozaril, Seroquel, Depakote and Paxil upon my psychiatrist. If a doctor didn't like Thorazine or a little Paxil (I take 50mg/day) for a short time, he wouldn't like a month of my meds.
If a doctor was actually willing to take all my meds for a month would he or she still prescribe them for me? Probably...but maybe, when I complain about side-effects or how they make me feel "different", I'd get the respect I deserve...not just a "whatever" attitude.
the wahtever attitude is not because the doctor does not care but rather because there nothing she can heqshe can do about it. it is the short phrase of "i really don't jave an idea what i can do. ant\yway you feel better, tryu to overcome the siude effects"
"To be honest, with just 10 people in each group, any or all of these results could be random chance anyway."
Why do say this? It's a common enough remark, but to be upfront I think it's an error. Did the authors (I haven't read the paper) not do significance tests? (How, then did it get published?) If they handled their data correctly so that outliers weren't driving their results, and their distributional assumptions were met, there's no reason why a significant result with 10 subjects per condition is more likely to be due to chance than a significant result with the same p with 100 subjects per condition. I've been perplexed about this category of remark about small sample size for long enough that I wanted to ask someone about the reasoning behind it.
Katie: Fair point, and I admit that it's unhelpful to reflexively cry "Small n! Rubbish!" whenever you see a small study.
However, there is an element of truth in it, because as you say, whether their p value is correct depends on whether
"they handled their data correctly so that outliers weren't driving their results, and their distributional assumptions were met"
But this is harder to do with a small n. If you have an n of 1000 it's easy to check whether the data are normal or not, and choose a statistical test accordingly; with an n of 20 it's much harder; it's also harder to know whether outliers are really outliers or whether the distribution is genuinely very variable... etc. In this case they don't mention either checking normality or looking at outliers. Though I confess that I've done a study of a similar size and I didn't either... I suspect most of us have.
taken to extremes, say I did a trial of a drug with 2 groups of 2 people (n=4), and I find that in Group A both of the subjects did really well (100% and 90% improved), in Group B both of them did badly (0% and 10%). I could run a t-test on that, and if I did I'd get p=0.006, but clearly I shouldn't. I should run more subjects.
As someone who is both a psychiatry trainee and a patient (I am on a relatively low dose escitalopram currently but have been on a number of drugs and higher doses in the past)I can say that psychiatrists are not as unsympathetic as some of these posts suggest.I actually think our Israeli friend has come closest to psychiatrists' point of view - doctors are very cost/benefit kind of guys. If hallucinations and delusions are markedly reduced by a medication, or apathy and suicidality, they consider nausea, weight gain, emotional blunting as acceptable costs.
Only the most dull-witted psychiatrist would dismiss these complaints simply because they hear one or more of these complaints from almost every single patient they prescribe these drugs to. We have tables that give some idea of how common and how strong the side effects of different drugs are and try as best we can (because idiosyncracies in each patient limits this approach to some degree) to tailor the choice to the patient - a common example is choosing the anti-pscyhotic least likely to produce weight gain in a young female.This is something not thought about in passing but of constant cause for concern, consternation and research in the field. So far all advancements in anti-psychotics for example have involved side effect profiles - no drug (except clozapine) has been any more effective than the first drugs used to treat psychosis, all that has improved is the chance of side effects. Drug companies score bonanzas if they create a drug more tolerable to patients. This is a huge component of their research programs.
However when facing an individual patient with a particular complaint the doctor's approach is to first suggest a specific solution - eat less, exercise more for weight gain, take an anti-nausea pill for nausea - but clearly for the more abstract effects of emotional blunting (which may as Neuroskeptic says be useful especially at the beginning of treatment, but may not be very desirable on improvement) doctors are a bit empty-handed and fall back on the benefits outweighing the (sometimes significant) costs.
Having said that doctors do like numbers and recognisable symptoms because like all guys with hammers they like seeing nails and they are likely to feel powerless when faced with complaints of reduced creativity, emotional blunting etc and may therefore respond in an unhelpful way (including minimisation and denial).
While I have some insight I do realise there is a big difference between an anti-depressant and an anti-psychotic and I have often proposed to my colleagues to try them with me to see what it does feel like. I have gotten little in the way of an enthusiastic response but I probably will try them to understand it better. However, given the debilitating symptoms they are the only drugs to offer some improvements in, I still feel ethically sound in encouraging them strongly to certain patients. Relapse is an ugly, potentially life destroying thing.
My friend was in deep depression and is on anti-depressants for quite long. This info was much useful. She's recovering now.
One wonders how many psychiatrists would be interested in employing the crazy wisdom of a qualified aghori to induce brief reactive psychosis in order to bolster their insight?
Ah, the quirks of the quadrupedal mind!
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