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Wednesday, February 13, 2013

If Medications Don’t Work, Why Do I Prescribe Them Anyway?

By Steve Balt, Psychiatrist
Thought Broadcast Blog
Originally posted January 4, 2013

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?

The entire blog post is here.

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