Antidepressants? You’re on your own

Some time ago, my Twitter timeline included a tweet about “a patient-centred & helpful discussion of whether and when to take antidepressants” offered by Prof. Stephen Lawrie (University of Edinburgh). I actually think that the text is neither patient-centred, nor is it very helpful. Here is why.

Here is the link to the tweet. You will see that quite a lot of people responded in kind, I was one of the few that objected to the text saying:

I find it extraordinary that a professor of psychiatry is telling ppl (with some qualifications) to self-diagnose and count symptoms. Is this what shrinks do? Count symptoms?! And I won’t even comment the idea that patients actually have symptoms.

I stand by the statement but here I would like to explore it some more. However, the text, is a bit too long for an in-depth analysis for a blogpost, so I will focus only on the section on whether to take antidepressants. Its title is:

So, when should I take an antidepressant?

And just the title is quite problematic. It suggests that first: it is ‘your’ decision, second, that you can simply take it. Neither, of course, is true. A third problematic implication is that you’re on your own taking the decision, which is of course not true either.

I must admit that for the life of me I don’t understand why, especially a professor of psychiatry, would like to write like this. If this is patient-centeredness, it makes no sense at all. No, people don’t just decide to start popping psychotropic drugs and any suggestion they do, is wrong.

But this is just the beginning. What does the Prof. Lawrie say about the moment of decision? Here it is:

This raises the question: how do you know if you are moderately or severely depressed? You could count your symptoms from the acronym in the Need to Know section above, though this is best done by a trained clinician. Or you could fill in a free questionnaire (here is a link to the dreadfully awful PHQ-9), such as this patient health questionnaire (while this too is designed to be administered by professionals, you can still score it yourself).

Have you noticed that a psychiatric diagnosis and the decision to medicate is reduced to counting symptoms? Is this really what shrinks do? You just roll off a few symptoms, the shrink totals them up, and Bob’s your uncle? Bloody hell, this is simplistic. Well, at least there is a library of literature saying that this is not what psychiatrists do. The idea that your symptoms are these obvious ready-to-inspect objects is so silly that even the diagnostic manuals don’t advocate ‘counting symptoms’. And indeed, it’s precisely for this reason (and a couple of others – there is a lovely history of the concept) that the concept of clinical significance was introduced. Deciding whether you have a symptom or two is not for the patients, even doctors are discouraged from self-diagnosis, for pity’s sake.

Moreover, I must admit that I am irritated by the idea of counting my symptoms. Not only do I not know what counts as a symptom (no, Prof. Lawrie’s account is hardly useful), I have no idea how to assess it. Doctors asking about symptoms or asking patients to assess them, really don’t seem to understand that symptoms are a medical way to construe patients’ experience, distress, discomfort or suffering. People don’t have symptoms, symptoms are invoked in the medical account of the patient’s narrative (see e.g., Mishler’s classical account of languages of the lifeworld and of medicine).

Also, I just despair at the audacity of telling the reader to do a questionnaire which should be administered by a clinician. I don’t even want to go into the discussion about whether patients should have access to such questionnaires.

And then we come to this loveliness:

Obviously, if you are too ill to be able to think clearly and comply with the demands of psychotherapy, or would simply prefer an antidepressant, then these are more reasons why you should take one.

I just don’t know whether to laugh or weep. I really would like to know how the author processes your self-assessment when you can’t think straight.

But it is the final paragraph that is probably the most interesting. It seems, the author stops talking to the person in depression and starts talking about someone else. Consider:

Yet another consideration is if you need or want to get better quickly – for example, this might be the case if a person is feeling suicidal, or if their depression is causing urgent employment or relationship issues. Psychotherapy can sometimes work relatively quickly but it tends to take months for a meaningful benefit, whereas antidepressants usually lead to a significant beneficial response in weeks.

The first sentence starts with a direct address, the 2nd person rendered by ‘you’ (in the context, it is safe to dismiss the possibility that the ‘you’ is impersonal) but it immediately changes to the 3rd person. All of a sudden, the author stops addressing the reader and starts talking about, presumably, a hypothetical person who is suicidal.

The shift is quite fascinating, as this is the moment when the author stops addressing his readers directly. So, if you are suicidal, Prof. Lawrie has nothing to tell you and prefers not to address you. One can, of course, think of a number of reasons why that might be, the most important of them is that it probably safer to avoid such a direct address. Just to be on the safe side. But I am disappointed to say, the shift also shows how disingenuous the whole piece is. If you’re really poorly, if you’re in danger, the shrink is uninterested in talking to you.  You’re on your own. The advice is not for you.

A reservation is needed. Of course, I do not claim that the author had this in mind or purposely excludes of people. I doubt very much this is the case. Rather, Prof. Lawrie operates within the normal parameters of psychiatry. And the article offers a disappointing insight into its workings.

I am not even going to discuss what ‘quickly’ means for the professor and what it might mean for the patient.

Let me offer some comments. This piece has been lauded as patient centred. In my view, it is anything but. Patient centredness is not about telling people that they can prefer an antidepressant, and which kind they should opt for. Patient centredness is to do with how a clinician sees the person sitting in front of them. Do they see a patient whose illness must be cured, or do they see a person in their entirety of social, economic, cultural contexts. It’s about a clinician understanding that telling someone who has a high-pressured job to avoid stress is only idiotic. This is patient centredness.

Nor is the piece a case of shared decision-making; for SDM is not about the patient having an antidepressant preference or counting their symptoms. SDM is about discussing options, weighing them up and presenting possibilities to the patient and then taking a joint decision how to proceed. That’s SDM. This article doesn’t do it either.

But most particularly, I dislike this piece because it suggests that the suffering person is on their own. That their task is to learn what depression is, and then to count their symptoms, and then decide whether they need antidepressants or not. This is psychiatry of the worst kind.

I keep saying that I am a critical friend of psychiatry (not that it cares much). That it is the best conceptual system in which to see mental distress. But if psychiatry is all about counting symptoms and encouraging the patient to do it, psychiatry should be scrapped. The quicker, the better. And so, I am so disappointed that so many thoughtful shrinks welcomed the article. Let me just say an article written by an eminent shrink doesn’t have to be wonderful. And Prof. Lawrie’s article is not wonderful at all! In my, a lowly linguist’s view, it should not have been published.

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