Withdrawals

Can be painful.

These posts examine modern psychiatry from a critical point of view. Unfortunately, mainstream psychiatrists usually react badly to any sort of critical analysis of their activities, labelling critics as “anti-psychiatry,” whatever that is. Regardless, criticism is an integral part of any scientific field and psychiatry is no different. As it emerges, there is a lot to be critical about.

If you like what you read, please click the “like” button at the bottom of the text, it helps spread the posts to new readers. If you want to comment, please use the link at the end rather than email me as they get lost and nobody sees them.

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Keeping up to date in medicine (and most other professional fields) requires a lot of effort so in most countries, some form of continuing education is now mandatory. Each year, practitioners are required to read and go to lectures and conferences to earn points before they can renew their practice certificates. Educational activities have to be approved in advance by some sort of credentialling committee, which is reassuring for the general public. It’s also good for the various professional bodies because it means they get to control what their members read and hear. In psychiatry, the control is tight: it’s difficult to get critical material published in mainstream journals, and much more difficult to get a lecture slot at a conference. It has reached the point where some influential people dismiss the main psychiatry journals as nothing more than the marketing arm of the drug industry but they also tell us what the big nobs are thinking – or what passes for thinking.

Besides the main journals, there are various industry handouts which proliferated as we moved to the internet. One of them, Psychiatric Times, based in Boston, is a very professional production which now comes out two or three times a week. They have regular writers plus they solicit articles from people who reflect their point of view. That just happens to be mainstream biological psychiatry, same view as the companies who shell out what I imagine would be up to $10,000 a week to produce the rag. However, their point of view seems to be shifting a little. Instead of drugs, ECT and more drugs, they’re now publishing articles that indicate they may be having second thoughts. Two from last week are interesting. One, a brief comment from Australia, looks at chronic use of antidepressant drugs while the other announces: “Exiting Antidepressants: A Needed Spotlight on Withdrawal.” They’re worth reading as they would not have been published a few years ago. Of course, the second article was tempered with a “counterargument” by Prof. Ronald Pies, from Tufts University in Boston and a colleague: “Antidepressant Withdrawal Syndromes: Listening to the Patient and Taking It Slow” (he meant slowly). I’ll state here that I do not regard Pies as a reliable commentator. For years, he has said that the “biopsychosocial model” is “the mainstay of academic psychiatry.” However, he refuses to provide evidence that this thing actually exists (it doesn’t). He also pooh-poohed the idea that psychiatrists ever espoused something called “the chemical imbalance model” of mental disorder. Psychologist Phillip Hickey showed that Pies has himself endorsed it. I’m not impressed by his lengthy case. He is committed to biological reductionism in psychiatry but can’t justify it. Instead, he relies on bluster and tight control of what gets published.

The article on the spread of antidepressants in Australia is based on figures from the Pharmaceutical Benefits Scheme (PBS), and they’re reliable. I’ve commented on this paper before but it’s worth repeating: in the 10yrs 2014-2023, for people aged over 10, the incidence of long-term antidepressant use has risen from 6.6% to 8.5%. That is a lot of drugs given to a lot of people at great cost, in the total absence of any convincing evidence that they’re doing what they’re supposed to do. In particular, in that time, the incidence of long term use in people aged 10-24 has more than doubled. If the drugs were harmless, perhaps it wouldn’t matter quite so much but they’re not. They have a huge range of side effects but we don’t know their long-term effect on the 10yo brain, which still has years of development to go. The majority of people who are started on these drugs are not given any information at all about them. When proper information is provided, most people will refuse them. The author is concerned that this trend represents over-medicalisation of normal human distress as prescribers jump to drugs before they actually know what’s going on in the patient’s life. These crucial points are simply not addressed in the sanitised “continuing professional education” lectures.

The second article, on withdrawing from antidepressants, is interesting, more for the fact that it actually appeared than from anything new it says. A few years ago, it would not have been published, especially as two of the authors aren’t psychiatrists. They emphasise that withdrawal from antidepressants is real but patients have long been told that it is a “recurrence of your depressive disease,” and to resume the drugs. These two trends, over-medicalisation and pretending that psychiatric drugs aren’t addictive, are enough to account for their constantly rising consumption. Are these drugs genuinely addictive? I have repeatedly asked psychiatrists who say they aren’t to take part in an experiment. The subject will take a common antidepressant for 6 months, let’s say mirtazepine, in standard dose. Start at 15mg at night for a month, then 30mg a night for the next month, then 6 months at 45mg each night. Throughout, record all side effects, such as drowsiness, confusion, lethargy, weight gain, sexual inhibition, akathisia, manic bouts and so on. At the end, stop the drugs abruptly (i.e. within 2 weeks at most) and record all effects. There were never any takers. Nobody even said: “I could do that without any trouble.” They all know perfectly well there would be a lot of trouble. I don’t know how many psychiatrists take their own drugs but it wouldn’t be many, that’s for sure.

The real concern here is the fact that young people are taking so many psychiatric drugs. That didn’t used to happen so it would help if we knew why. We know it’s not genetic as the genome doesn’t change from one generation to the next. All anybody ever says is “stress.” OK, that’s a good place to start, so let’s define “stress” so we all know what we’re talking about. Here we have a problem. Last time I looked, I found it had seven (7) different meanings. The word has now become useless, for which we can largely blame the American Psychiatric Association, as in “PTSD.” This august body forgot to distinguish between ‘stress’ as the external threat and ‘stress’ as the internal response, between stress as a noun, an adjective and as transitive and intransitive verbs:

Work is such a stress, the whole place is full of stress, I’m always stressing about it. My boss stresses me to the point where I’m so full of stress that I’m about to have a stress attack. I’ll have to destress on somebody before I go out on stress.

The confusion comes from the person who introduced it to medicine, Hans Selye (1907-82, pronounced Sell-yea), a Hungarian physician who migrated to Canada and wrote extensively on what he considered the general response of an organism to non-specific external pressures. In fact, he wasn’t sure what terms to use so he borrowed two from engineering: stress and strain. For them, the stressor is the external force acting on a body to deform it; this induces an internal response, properly known as strain. However, at that stage, his English was still a bit scratchy and he mixed the two terms up, so we’re stuck with this ridiculous term that is used to “explain” everything from baldness to fallen arches.

Anyway, do the modern generation have things to worry about that we old codgers didn’t have? Yes, I think they do, a lot in fact, and it’s steadily getting worse, not better. The olden days weren’t all fun, we had nuclear war to worry about. In about 1957, Neville Shute, a British-Australian author wrote a book called On the Beach, about the end of the world after a nuclear war in the northern hemisphere. It was dramatised on the radio and later made into a film but I didn’t see it: the book and the radio play terrified me for months but we survived. These days, kids have probably the worst set of politicians in world history with their pudgy fingers hovering over the buttons to start a nuclear war; if that doesn’t get us, global warming will; if they survive that, there aren’t any jobs but they have huge university debts to pay off; if they could get a job, houses are unaffordable so both will have to work but child care is too expensive and the grandparents live too far away to help. For the first time in the history of this country, young people cannot expect to do better than their parents.

That’s a fair bit to worry about, so what is society’s response? Put them all on drugs. Clearly, that doesn’t deal with the stressors at all, it merely shifts the blame, away from a dysfunctional society and into the individual – and sells lots of drugs. That way, the larger society doesn’t have to look at itself and ask “What are we doing wrong, what sort of world are we handing to the new generation? Do we need to change ourselves?” Mainstream psychiatry’s role in this is to spread the word that all mental problems are actually brain problems, that what we think are life problems are actually irrelevant to the biology, and they have a drug for each of them. Trouble is, psychiatrists actually believe this themselves, which means they’re blind to the obvious fact that mental problems produce mental symptoms. They don’t believe it is possible: if you have mental symptoms, it means your brain is misfiring and needs drugs and/or electricity and/or magnetism etc. to get back to normal. Thus, they never deal with the actual problem but conceal it under a shopping bag full of very powerful drugs; if the drugs are stopped, the problem is still there, along with the withdrawal effects. Some external problems may resolve themselves but if it’s internal, a personal issue, it won’t go away.

The commonest internal cause of a recurrent or persistent depressive state is anxiety; people can get caught in self-reinforcing anxiety states so the drugs can never do any more than numb the symptoms, which flare up the day the drugs wear off. Because psychiatry is obsessed with depression, it doesn’t take anxiety seriously, dismissing it as “comorbid” or “the worried well.” However, anxiety is very serious, as well as common. About 15% of the population are significantly anxious at any one time, more if we add all the people who keep themselves numb with alcohol or drugs or computer games or running marathons or whatever. And anxiety ruins your life: it’s said that a full-blown panic attack is the worst experience a human can have and still survive.

Anxiety problems appear to be getting more common, meaning more and more people are living with significant disability which nobody is able to explain to them, which the drugs are making worse, which seriously affects their social and work lives, and which shows no prospect of getting better. That’s a very depressing scenario: any non-anxious person who suddenly has that lot dumped on them would get depressed, too. Anxiety is not a personality weakness as nobody chooses to be anxious, you can’t will yourself to be anxious. It isn’t a dozen different “diseases” as there’s only one sort of anxiety, the scary sort, even though it can be expressed in different ways. In addition, people try to control it their own way, e.g. withdrawing from life, drinking and drugs, controlling people, compulsive cleaning, eating, promiscuity, gambling, etc. which muddies the waters and diverts attention from the real problem. However, people normally won’t reveal this. Anxious people tend to see their anxiety as a moral failing so they keep it to themselves. They’ll talk about feeling depressed because all the advertisements in the public toilets say it’s a biological disease like diabetes or blood pressure, but not anxiety, Oh no not me, especially teenagers and young adults of the male persuasion.

This is set up for disaster. On the one hand, psychiatrists are convinced each and every mental condition represents a separate biological category; that mental events must have a biological cause; that anxiety is not a “serious mental illness”; so they don’t believe chronic anxiety can cause depression in its own right. On the other hand, sufferers don’t want to talk about it so they’ll keep quiet if they can. On the third hand, we have heaps of expensive, addictive and troublesome drugs that don’t “cure” anything but once started, are difficult to stop, which is a fantastic business model if you’re in the business of selling pills. However, if from the beginning, people are asked the right questions, they will eagerly spill the beans and won’t need the nasty pills.

Taking a history isn’t difficult but if people aren’t asked, they won’t say anything. Psychiatrists mostly don’t ask, which is why they think anxiety isn’t important. In taking a history, I asked the same questions in the same order using, so far as possible, the same tone of voice. Time and time again, people said things like: “I’ve been seeing psychiatrists in big hospitals for ten years, and nobody ever asked me those questions.” That’s pretty revealing. Every patient got these questions in this order, to show the nature of their symptoms, the intensity and the causes. First group of questions covered the physical and mental symptoms of anxiety:

In your ordinary daily life, do you have bouts where you feel tense and jittery, you get agitated or worked up? What do you experience with these? Can you settle or are you restless and fidgety? Do you get to the point where you shake? Where do you shake mostly? Do you become sweaty or your palms become sticky? Does your heart race or thud? Does your stomach churn, or feel hollow, hungry, knotted or butterflies feeling? Can you eat when you’re very agitated or do you feel you’ll vomit? Do you ever actually vomit or is it just froth? Do you feel tight in the chest or short of breath? Do you get a dry mouth? Do you have a tight feeling in the throat, so you can’t talk or swallow properly? Do you stutter or stammer or lose your words? Do you feel dizzy or light-headed, clumsy or unsteady on your feet? Do you have a feeling of the walls closing in, you feel trapped? Do you have the feeling that when you look at the world, it’s different, or you’re different? Does that mean different from your normal self or different from others?

During a bout of agitation, how do you feel inside? Do you feel frightened or angry? What do you do, yell or bang things, or do you go quiet and try to get away? Can you continue with your work during them? In an average day, how many bouts of agitation do you have? Roughly how long does each one last, until you’re back to normal? Now what brings them on, what causes the agitation?

In your ordinary daily life, is there anything you’re frankly scared of, such as heights, confined spaces, wide-open spaces? What about thunder and lightning, sudden noises or being touched unexpectedly? Do you startle easily? What about water or darkness, dirt or disorder? Contamination of your hands, does that scare you? What about weapons such as firearms or knives, do they scare you? Any animals scare you, such as rats or bats, frogs, toads, snakes, spiders, cockroaches, creepy-crawlies such as scorpions or centipedes, maggots, worms, leaches, birds, cats, dogs? What about dealing with people, do you feel scared in a crowd, standing in a queue with people straight behind you, or public speaking? Appointments and interviews, tests or exams, do they scare you? What about public transport, meeting strangers or talking to people on the phone?

Threats or criticism, do they upset you badly? Arguments or disputes, confrontation or saying No to people? What about letting people down, causing trouble or giving offence, does that make you give in? Do you try to keep the peace regardless? What about the thought of loneliness, humiliation or disapproval, do they scare you? The thought of making a mistake or failing at anything? Is that enough to stop you trying something new? What about illness or disability, death or mental illness, do they scare you? Hospitals or dentists, blood or needles?

Any groups of people scare you, such as police, military, bikies, black people or foreigners, drunks, junkies, teenage gangs, or just aggressive people in general? Do you have to get away from them? What about people in authority, do they scare you?

If you believe anxiety is trivial, just bored people worrying needlessly about themselves, you won’t ask about it. If you don’t ask, you’re not taking anxiety seriously and you’ll never know, partly because people won’t volunteer it but also because they have never sat down to consider all these points. This can be quite shocking: “I had no idea it’s that bad.” Similarly, if you believe mental trouble can’t have mental causes, you won’t be able to draw a link between disabling anxiety and the despair it causes.

Anyway, back to the two articles. After a long commentary on the withdrawal article, Dr Pies and his friend concluded:

There is much we still do not know about the (antidepressant withdrawal) phenomenon … This issue is far from settled.

Really? Seventy years after they were introduced, and you still argue over the extent and severity of drug withdrawal? How come? Oh, the studies haven’t been done, you say. So why are the drugs still being prescribed? Would you buy a ticket on an aeroplane without knowing where it was going to land? Of course not, but in the case of antidepressant withdrawal, the answer is that mainstream psychiatry just doesn’t want to know about it. If you don’t ask, you will never know and if you don’t know, you can’t be blamed.

Psychiatric research is driven not by the urge to find out what’s going on but by the need to “prove” that all mental disorder is caused by physical conditions of the brain. That’s what they believe, now all they need is the evidence. The mainstream never questions this ideology. People who do quickly find they’re no longer in the mainstream. This isn’t how science is conducted, as astrophysicist Carl Sagan (1934-1996) observed:

It seems to me what is called for is an exquisite balance between two conflicting needs: the most sceptical scrutiny of all the hypotheses that are served up to us and, at the same time, a great openness to new ideas. If you are only sceptical, then no new ideas make it through to you. You never learn anything new. You become a crotchety old person convinced that nonsense is ruling the world (there is, of course, much evidence to support you). On the other hand, if you are open to the point of gullibility and have not an ounce of sceptical sense in you, then you cannot distinguish useful ideas from worthless ones. If all ideas have equal validity, then you are lost; because then it seems to me, no ideas have any validity at all (from “The Burden of Skepticism” in Skeptical Inquirer 12 (1) 1987)

The idea that “all mental disorder is caused by physical conditions of the brain” is now a useless idea but it seems psychiatrists won’t give it up for fear they’ll go into withdrawals, poor things.

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My critical works are best approached in this order:

The case against mainstream psychiatry:

McLaren N (2024). Theories in Psychiatry: building a post-positivist psychiatry. Ann Arbor, MI: Future Psychiatry Press. Amazon (this also covers a range of modern philosophers, showing that their work cannot be extended to account for mental disorder).

Development and justification of the biocognitive model:

McLaren N (2021): Natural Dualism and Mental Disorder: The biocognitive model for psychiatry. London, Routledge. At Amazon.

Clinical application of the biocognitive model:

McLaren N (2018). Anxiety: The Inside Story. Ann Arbor, MI: Future Psychiatry Press. At Amazon.

Testing the biocognitive model in an unrelated field:

McLaren N (2023): Narcisso-Fascism: The psychopathology of right wing extremism. Ann Arbor, MI: Future Psychiatry Press. At Amazon.

The whole of this work is copyright but may be copied or retransmitted provided the author is acknowledged.