Themes from people’s experience of antidepressants

Many so-called treatment resistant depressed patients do not respond adequately to two antidepressant medications given one after another. The question of the efficacy of antidepressants is still an open issue in the scientific literature because of methodological problems with the clinical trials (see eg. previous post).

Crowe et al (2023) identified four themes from a meta-analysis of qualitative studies examining patients' experiences of antidepressant medication. These were:-

(1) The only option available. This was partly about the sense of ‘needing something’, often quite quickly. People were generally more accepting of taking antidepressants when in acute crisis but were more ambivalent about taking them outside this context. Some felt they had to take antidepressants because of what the doctor said and even felt bullied into taking them. Some said they got relief from their first prescription but over half in one study had a trial of more than one antidepressant before getting any relief. Not everyone took the medication as prescribed, with some deciding themselves when to take it and others choosing not to even take the prescription. Most participants described feeling that there was no other treatment option available and were desperate for relief.

(2) Stigma associated with ‘biochemical deficit’. Participants in 14 studies described how the medical construction of their experience as a biochemical abnormality was stigmatising. Participants may feel different or damaged and reliant on medical expertise. Having been positioned into a passive position with the doctor having control may have shamed some into taking medication. Just using medication itself was linked to the stigma by many. Most participants in this theme described being told they needed antidepressants for their ‘biochemical deficit’. For some the deficit was constructed as something that would require on-going treatment. The doctor may state as fact that the person was biologically flawed even though there was a lack of evidence for such a view. 

(3) Not myself. In weighing up the benefits and risks, participants in 6 studies, if they took medication, described it as helping their functioning, noticing improvement in mood and being given a sense of hope on starting. However, this was often offset by experiences in which they felt the medication was masking the real problem or altering their experiences of themselves and others. This was captured in one study where participants described unbearable side effects, undermining emotional authenticity, masking real problems and reducing the experience of control. Most people commonly experienced a flattening of emotional responses which included feelings of being ‘dulled’, ‘numbed’, ‘flattened’ or completely ‘blocked’, as well as descriptions of feeling ‘blank’ and ‘flat’, affecting their relationships with others and how they saw themselves. Some described how antidepressants made them feel worse than the original depression.

(4) A vicious cycle. Patients in 8 studies identified issues in relation to discontinuing antidepressants. They often described wanting to discontinue antidepressants but had a fear of relapse. Discontinuation was associated with withdrawal symptoms, ranging from mild to severe. Fear of relapse and the experience of withdrawal symptoms meant participants felt compelled to keep taking antidepressants when they no longer wanted to.

Disclosure of industry payments to the healthcare sector

I've mentioned Peter Gordon before (see previous post). He raised a petition for a Sunshine Act for Scotland in September 2013 to make it mandatory for healthcare workers (including academics and allied health professionals) to declare fully any payments from industry and commerce (see his blog post). 

The UK government has recently issued a consultation on disclosure of industry payments to the healthcare sector (see BMJ news report). This is based on a recommendation from the Cumberledge review that investigated the harm caused by the use of Primodos, sodium valproate and pelvic mesh (see BMJ news report). 

Peter argues that government proposals for disclosure need to go further (see his blog post). It will be interesting to see the Royal College of Psychiatrists' response to the consultation. Peter tells me that the College has given no response to the Cumberledge review. Still, two high profile media doctors have been persuaded to become conflict-free (see BMJ article). 

Updating psychiatry’s biology

I’ve mentioned John Dupré previously (see post). His book The metaphysics of biology: Elements in the philosophy of biology (2021) looks at four general philosophical perspectives on life: vitalism, materialism, mechanism and organicism. Vitalism is generally derided because it is seen as postulating a vital thing or substance that is unique to life. Materialism, in the sense of the non-existence of the immaterial, is obviously true but, in this sense, a narrow claim. It is often strongly associated with the thesis of mechanism that life can be explained as a machine. Organicism, like vitalism, asserts that different principles apply to living systems. As Dupre says, "The point of difference is that it is not that there are principles that don’t apply to matter, but that these principles apply only when matter is organised in a particular way.“

An organism exhibits a mode of organisation very different from a machine. It is more than the sum of its parts. Cells and bodies are not well-defined structures but actually stabilised processes (see eg. previous post). Vitalism attributes the wrong kind of specialness to life, but nonetheless, living beings have a purposiveness that cannot be derived from mere physical-chemical processes.

Psychiatry, therefore, needs to update its biology from mechanism to organicism. Mechanical explanations are insufficient for an account of the totality of human nature. Psychiatry's primary object is not the brain but the person living in relationships. This fundamental failure to appreciate this philosophical reality is damaging psychiatry.

Taking relational psychiatry forward

I completed two years in semi-retirement of a five year part-time PhD on ‘The foundations of critical psychiatry’ at the University Department of Psychology in Cambridge in 2017/9. My supervisor left after 4 terms and I couldn’t find a replacement! Still, I managed to write three articles in Royal College of Psychiatrists’ journals: (1) Twenty years of the Critical Psychiatry Network; (2) Critical psychiatry: An embarrassing hangover from the 1970s?; and (3) Toward a more relational psychiatry: A critical reflection. An interview with Awais Aftab expressing my views about critical/relational psychiatry is to be published in a forthcoming book. 

As I said in the interview, part of the reason I changed the name of my blog from critical psychiatry to relational psychiatry was to try to move on from debates about so-called anti-psychiatry and incorporate more recent perspectives from anti-cognitivist phenomenology and enactivism and the tradition from cultural psychiatry. Key contributions here would be: two books by Thomas Fuchs: Ecology of the brain: The phenomenology and biology of the embodied mind (2018) (see eg. previous post); and In defence of the human being: Foundational questions of an embodied anthropology (2021) (see eg. previous post); the book Enactive psychiatry by Sanneke de Haan (2020) (see eg. previous post); and the contributions over many years by Laurence Kirmayer (see eg. previous post) including the book Re-visioning psychiatry: Cultural phenomenology, critical neuroscience, and global mental health (2015), of which he was the first editor. 

Other initiatives include the Relational Practice Movement, which has developed out of the therapeutic community movement (see eg. previous post). It has produced a Relational Practice Manifesto. Russell Razzaque has also produced a Relational Psychiatry vlog. He is now the Presidential lead for compassionate and relational care at the Royal College of Psychiatrists. It would be nice to think that the College could help to bring all these strands together to make psychiatry more relational.