What follows is a doctor-patient interaction that I hope will become more commonplace across psychiatric outpatient clinics:
[After a 15-minute initial interview]
Psychiatrist: Mr Smith, it is clear you are suffering from a depressive illness.
Mr Smith: Oh, OK. It’s reassuring to hear that you know what’s wrong with me.
Psychiatrist: Yes, a clear-cut case of major depression, an increasingly common mental disorder.
Mr Smith: It’s good that you’ve pinpointed the cause of all my distress. But can I ask, how can you be sure I have this illness?
Psychiatrist: You’ve got all the classic symptoms: low mood, suicidal thoughts, loss of appetite, not enjoying life – there is no doubt. Also, you told me about how your father suffered prolonged periods of low mood; these things run in families you know.
Mr Smith: So I’ve inherited this illness from my father?
Psychiatrist: Yes, in all likelihood.
Mr Smith: So a gene has been identified for this thing you call depressive illness?
Psychiatrist: Ah, no – it seems like many genes make a contribution. We’re as yet unsure as to which ones, but there’s lots of research underway to find out.
Mr Smith: But it is primarily a biological problem, an illness like any other?
Psychiatrist: Yes
Mr Smith: I’m so relieved you’ve identified the source of my difficulties. I’m embarrassed to admit that I was thinking my recent despair might have had something to do with the death of my parents earlier this year, my wife leaving me for my best friend, losing my job last month, and the assault I suffered during karaoke night at my local pub. How stupid of me! I’m pleased I consulted a medical expert who can diagnose the true source of my problem so quickly.
Psychiatrist: Don’t mention it – it’s my job.
Mr Smith: But, with respect doctor, you haven’t carried out any blood tests or brain scans, so how can you be sure I’ve got this illness?
Psychiatrist: We don’t need those tests to identify a depressive illness. We can diagnose from the symptoms you describe.
Mr Smith: So how is it decided that these particular symptoms indicate that I have got this biological illness? I once read some mumbo-jumbo that diagnoses such as these were dreamed up by some blokes sat around a committee-room table in the USA, by a show of hands. But of course that isn’t the case, is it doc?
Psychiatrist: Eh, well, not really … these people are medical experts, consultant psychiatrists.
Mr Smith: Ah, that’s good to hear. So these experts know there is some underlying biological abnormality purely from the changes in my mood and behaviour?
Psychiatrist: Yes, that’s it. So shall we move on to discuss … …
Mr Smith: Sorry to interrupt, doc. But what precisely is this biological abnormality that’s causing all my distress?
Psychiatrist: We’re not entirely clear about that; probably something to do with lack of a chemical messenger in the brain.
Mr Smith: Are you referring to serotonin?
Psychiatrist: Yes that’s it. So let’s move on to look at the treatment options that … …
Mr Smith: I thought these chemical imbalance explanations of mental distress had been shown to be a load of bollocks.
Psychiatrist: Well, eh … there has been some debate … … and we’re not entirely sure about the exact biochemical mechanism underpinning this mental disorder. But the good news is it doesn’t really matter as we can give you antidepressant medication that will make you feel better.
Mr Smith: Four pints of cask ale each evening makes me feel better, but I’ve never regarded that as a long-term solution.
Psychiatrist: Alcohol is most definitely not the answer, young man. It will lead to further physical and psychological problems, and you risk becoming dangerously dependent on it.
Mr Smith: Just to be clear in my mind, doc, these antidepressants don’t have these disadvantages?
Psychiatrist: No… … not really. There could be a few minor side effects and, unlike alcohol, they are safe and most certainly not addictive. So take this prescription to the pharmacy and … …
Mr Smith: Sorry for interrupting again doc, but I think I read somewhere that these depression pills often cause some nasty side effects, like crushing headaches, nausea, insomnia, weight gain, diabetes and – God forbid – erectile failures and being unable to pee. Perhaps this is total nonsense?
Psychiatrist: Listen young man, there has never been a medication invented that doesn’t sometimes cause side effects. In regards to antidepressants, these side effects are typically minor and last no more than a couple of weeks. The antidepressant effect takes a few weeks to kick in, so you mustn’t stop them just because of a few minor teething problems.
Mr Smith: So you’re recommending I take these tablets for a long time? Weeks and months rather than days?
Psychiatrist: Yes, that is correct.
Mr Smith: But aren’t they addictive?
Psychiatrist: No, no, no, no – withdrawal is rarely a problem with antidepressants. These psychiatric medications are not like alcohol or street drugs.
Mr Smith: So that article I read in the Guardian was a pack of lies?
Psychiatrist: What article?
Mr Smith: The one that stated that a comprehensive review of the research had found that over half of longer-term users of antidepressants suffered significant withdrawal symptoms, many of these being severe and debilitating, and lasting for many months?
Psychiatrist: Look young man, all I can give you is my expert, impartial advice; it is up to you whether you … …
Mr Smith: Who are Eli Lilly and Pfizer?
Psychiatrist: What?
Mr Smith: I’ve just read them on your coffee mug and wall calendar?
Psychiatrist: Get out of here before I call security.
***
Thanks ever so much Gary,
I laughed as you described it perfectly. How a psychiatrist can be so sure. That a person’s life events are ignored. There are no tests, scan or investigations for diagnosis. It’s the ‘I am right and here is the cure’. In my humble opinion (please note I am from a medical family) there is no other area of medicine that behaves in this particular fashion. One of the family mottos is, ‘Any clinician who claims to know everything is dangerous.’
Thank you for the blog Gary, We place so much faith in the medical model and it’s solutions for mental health problems. The people I see are often recommended to me because they question the 10 minute consultation and a re offered medication as a first line intervention. Good therapy is not cheap and we sometimes get sucked into a McDonald quick fit solution that aims to get rid of bad feelings then we will be ok.
Thankfully, this is on the change in the UK but therapy is sometimes cheapened when newly qualified inexpensive graduates are left to offer help to people with complex difficulties.
I am glad for the MAD organisation and the views of those to challenge the medicalisation of human distress.
Thank you
Baz
This was a nice article. What you are essentially calling for is people to have adult to adult relationships with doctors and to have some basic knowledge of science, including having an awareness of how people in power are perfectly capable of manipulating science given that the population at large tend to drop the study of the sciences when they leave school. Although it might be unlikely that many people would be this challenging of a diagnosis when they present to a doctor in distress, it is perfectly possible to have this type of conversation in retrospect, although it will take time for this approach to filter through the medical system.
I have an example of what I mean. Earlier this year I went to see a nurse at a surgery where I wasn’t registered and therefore they didn’t have my notes. It was about a non-mental illness question however I decided to bring up the problem of my own diagnostic label. I explained how I had been given a diagnosis after a breakdown and that my partner at the time had used that label against me, telling me my thoughts were wrong and contacting my friends whenever I tried to leave him to tell them I was having a relapse of my ‘illness’ to prevent any of them helping me get away. The nurse sat there in silence as I told her my story and then she looked at me thoughtfully and told me a tale of some training she’d been on regarding domestic abuse which had ended up with the woman being treated for a psychiatric condition. The nurse told me that everyone at that training had been screaming at the speaker – why wasn’t the guy the one being treated for a psychiatric condition? Why was the woman seen as mad? She understood me. She was the first person I had ever met in the NHS who genuinely listened to me and I am convinced this is because, not having read medical notes about me before I entered her consulting room, she didn’t pre-judge me as mad, listened to my story, and then realised the truth behind what I was saying about the appalling reality that comes with having to live with a psychiatric label.
So, she suggested that I should speak to one of the doctors in the surgery and tell him my story. I felt great about this and did as she suggested. I told the same story about my situation to a doctor, about how my partner had become manipulative to me due to my diagnosis, and how I now know – due to the MSc in Psychology I subsequently did to prove my own sanity to those I care about – that diagnoses are not scientifically valid and that I shouldn’t have to live with a medical label that can genuinely cause such major problems for a person. Well, I was dismayed by his reaction having felt so buoyant from the nurse’s comments. He asked me if I was okay, if I was being manipulated now, if I had a current partner who had persuaded me to come and talk to him! I.e. he did not believe me. It was too difficult for a GP to believe that a person could have suffered psychological abuse based on a doctor’s diagnosis. It was easier to start talking down to me as a vulnerable woman – seeing me as a child in comparison to his parental all-knowing medical position.
I have written this for two reasons. One is because I liked your article and I believe that the idea of well-informed patients is the real way the current inhumane practices of handling mental distress can be ended. The other is to point out that the whole of the medical profession needs challenging on this one – not just the psychiatrists themselves. That nurse was great. The patronizing mentality I experienced from the GP, however, worries me.
E.M. Carr – I appreciate your detailed and interesting response. So sorry to hear about the GP’s attitude after your hopes had been raised by a nurse that actually listened to your story.
I write stuff like this, yes, in the hope that it might contribute a little to the empowerment of service users to actively involve themselves in discussions with mental health professionals. Also, I hope that those with more power – professionals, journalists, politicians – might read it and, as a result, be less inclined to spread damaging myths & biomedical claptrap.
Thanks again for your feedback.
Best wishes
Gary
Hi Gary,
Thanks for your response to my comment. I was wondering if you could advise me on how to become more involved in getting my voice heard as a former victim of the horror that is the UK’s ‘treatment’ of people going through life traumas. As I mentioned, I have subsequently done an MSc in Psychology so that no one can tell me, as they once did, that I can never have insight into my ‘condition’ which means I am able to remain fully informed of what the current scientific papers have to say on the topic. I am also a full-time writer and have already written two books. Despite this, and perhaps because I am using a pseudonym here, I am finding it very difficult to get my voice heard on this issue. This website, for example, has not replied to either of the blog submissions I have sent and this silence can be as off-putting as the refusal to answer me that was once my reality in the face of psychiatrists. I appreciate that there may be a massive amount of submissions, but a response would at the very least be polite and I can’t help but think I’d get one if I was considered important like a journalist. Who knows, though – perhaps I am important behind my pseudonym!
Since I am currently unable to get articles published on this site which I actively support, what I am currently doing is making sure everyone I know and love becomes aware of what is going on in psychiatry. I am also, like I wrote in the earlier comment, trying to now talk directly to medical staff themselves. If I can change opinions even in a small way that would be a start, but I’d welcome your advice on how to get some of my wider writings on this issue published. It is essential that other people in the same position I was in all those years ago have a way of finding out that they are not chemically imbalanced and that life really does go on if you fight against the psychiatric labels.
E.M. Carr
I’m so sorry to hear that you are experiencing difficulty getting your articles accepted for publication. The MITUK site is always keen to receive blogposts from people with lived experience of the mental health system, so I can only assume that your previous submissions have slipped through the net – I understand someone from MITUK admin has already been in touch with you to discuss the issue. As for achieving publication in the mainstream media, this is always a challenge – I’ve had several unsuccessful attempts to get articles accepted by The Guardian & The Times; it definitely helps if you are already a big name. And then, of course, there is always the option of your own blog. Anyway, I wish you success in your future endeavours to spread the word.
Dear E. M.Carr,
I am so sorry to read of what you have been through and pleased that a nurse listened to you. It is a real shame about how you GP received your story.
Congratulations on obtaining your MSc.
x
This is indeed what we are asked to churn out Gary. The detriment to patient is clear but we have a way to go and there are many people I know, who are aware, some not…willfull blindness is common during and after university. The thought may be that the job itself necessitates decency, in the sense we are without barriers.
We need to step into the foreground and look back at what we have done and what we are doing. What is the merit? What is the goal? What is my goal? Does God exist just as many of these patients claim?
Thank you Gary, for annunciating.
Thank you for your interest, FC, and for taking the time to comment.