Reply to the Editorial: Has psychopharmacology got a future?
The British Journal of Psychiatry (2011) 198: 333-335.
Film version of ‘Gilbert Farie Re-visited’: https://vimeo.com/43620205
Yes, psychopharmacology has a future. I do not think that we need to worry overly, for as long as humankind remains conscious, we shall have need to ease suffering. We may regard this as our profession’s mental business, but it is no less so in other disciplines within medicine and indeed humanity as a whole. We are now in an age (not post-modern, whatever that is) where the simple descriptions of heroes and villains of Ivan Illich’s 1975 theory of medicalisation are no longer adequate.
Gilbert Farie, (pronounced fairy) you will not have heard of, for he is a forgotten village Pharmacist who practised back in Victorian days. However his ghostly spectre is raised here to remind us that we should be wary of reducing debate into that which is ‘good’ or that which is ‘evil.’ Gilbert Farie was the dwarf pharmacist, hunched, red cheeked and monocular in vision, who each day dispensed from his pharmacy the cough medication for the boy who was Robert Louis Stevenson.
Gilbert Farie could sell anything, and literally did. He monopolized the Spa town of Bridge of Allan, made a fortune and married an heiress. He was widely unpopular as his only pursuit was of self advancement. No wonder he crept into the nightmares of young Robert Louis Stevenson. By now, you will have gathered, that Gilbert Farie was the counter of Dr Jekyll. Yes, Gilbert Farie was Mr Hyde.
Today, Gilbert Farie’s pharmacy still runs, and with an interior that is largely unchanged, it is where for the last 14 years I have picked up my prescription of Paroxetine antidepressant. My revisits to Gilbert Farie, have given this doctor (and once patient) time to offer some reflections on prescribing mindfully.
The first revisit. Confirms that we must not be drawn into a simplified dualistic – Jekyll and Hyde like – interpretation of psychopharmacology as either good or bad. Here I share the plea of Professor Cowen and Professor Reid.
The second revisit. Confirms that depression can be a monstrous illness. Those who ask that antidepressants as treatment be removed, baby and bathwater, forget the suffering caused by the creeping Hyde. Mood is not wholly biological, but can have a dimension that is out-with social and cultural ‘proximate’ causes. Here Dr Jekyll reminds us that antidepressants, when prescribed carefully, may be life savers and can certainly reduce great suffering.
The third revisit. Quantitative research has been the “objective” basis for mass prescribing: but can it be harmful? Here I talk of our oath primum non nocere. I completely disagree with Professor Reid that, if anything, we are prescribing antidepressants conservatively in Scotland. Does ‘Hyde’ lurk in one in nine of us as in-built disorder? It saddens this writer, monstrously actually, that so much of mankind now explains behaviour in terms of a ‘disorder’. Surely Robert Louis Stevenson would ask are we perhaps ‘hydeing?’
The fourth revisit. 14 years: that is quite a time to be on an antidepressant. Where are the studies beyond six weeks on these medications? Here one cannot even simplify into good and bad as studies are not there. Yet antidepressants have been around 58 years. Yet again we return to the proportionality principle and research.
The fifth revisit. My doctors told me it was my ‘chemical imbalance’ and that we must defeat depression. Many in my profession will tell me that my depression was neuro-genetically determined. However, the stress that shaped Peter (his narrative that doctors do not have time to understand and actually is not so easy to explain) gives a much more understandable, ontological reason for heightened anxiety and negative thinking.
The final revisit. Now I have long since accepted that I cannot stop paroxetine – it is like my shadow. I am reconciled to this and, you may be surprised, I seek nobody to blame. Explicitly however, I do not want to be remembered as a ‘seroxat sufferer.’ In my films I use images to carry messages, as I fear that my words lack the “objective rigour” that our profession today demands (is this stigma?) However, it is here that I admit irritation with Professor Cowen and Professor Reid in their academic writings of the last few years. Perhaps they would not suggest today that it is all so simple as a ‘chemical imbalance’ but there is little humility in their defensiveness and reluctance to acknowledge the pervasive marketing of the pharmaceutical industry, that has flourished in a needy world. Today the next market, beyond the off-label elderly, would appear to be neuroprotection. Unlike Edward Shorter I do not blame Pharma for all. However, the confounding of marketing with education, and the concealment of evidence when it does not reveal the answer so wanted is monstrous. It is greed before care. Here we cross the border of ethical malfeasance and apology is due. Surely it is the task of academic psychiatry to define the boundaries of psychiatry and to teach doctors about the discriminate use of psychotropic drugs. Gilbert Farie has been working too hard: he needs a rest.
Certain scientists may hate this, but if my past depression is to be understood, then both numbers (that which is quantifiable) and words (the qualitative) should be understood as equal forms of measurement.
As a practising psychiatrist I still prescribe antidepressants, but it was paroxetine and particularly its withdrawal, I was considering at a recent College meeting of psychiatrists. Our profession has to accept that evidence was edited by GlaxoSmithKline in the case of this drug. It would appear that we have failed to grasp this nettle: our distinguished speaker, professor of psychopharmacology asked his professional audience of doctors with Hyde-like sarcasm: ‘and antidepressants cause suicide?” To this, he gained the clapping cheers of today.
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