Those who know me and have either seen my practice or been on the receiving-end of my doctoring will know that medicines, that is tablets, capsules, pills and potions are not usually my first route to care or treatment.
I like to find-out what is going-on, the story, the signs and symptoms, perhaps analyse x-rays and blood results, ideally with the patient, their family and the clinical team and work-out what is best to do.
In a world of polypharmacy – that is, too many medicines, I frequently start by stopping drugs that are likely the cause of the harm.
Perhaps providing some more detail as to who, or what, I am will help with the rest of the discussion.
I am a physician.
This is different from saying, I am a surgeon or a psychiatrist.
Those are the main branches of medicine.
Sure, doctors find themselves in other fields – public health, microbiology, pharmacology, but, most of us fit into the three camps I have suggested.
The differences are best explained in the following joke;
A surgeon thinks little and does a lot,
A psychiatrist thinks a lot and does little,
A physician thinks a lot and does a lot.
Sure, if you are a psychiatrist or surgeon you might disagree – I am not saying that you guys are lazy or stupid, and, yes, it really is just a joke.
The principle however is that a physician is the guy (or gal) who works out what is wrong and decides what should be done; they use their diagnostic, analytical and care-centred skills to determine the best way to support a person.
Physicians accept all-comers, as all disease can, they believe be rationalised medically, that is, broken-down into its constituent parts, bits and pieces of organs, tissues, function and malfunction.
Physicians tend not to cut-out the problem, instead they establish its nature and, if they can’t find the cause or the answer they keep going, they mush until something crops-up or, if they are of a reductionist bent, they concede, ‘I can’t find anything wrong,’ although, given the complexity of the world in which we all live, there is always something wrong, this then takes us in a circular argument, often back to the GP (mostly physicians) who then ask another physician for advice.
Ironically, despite this initial jump into what doctors do, that isn’t my focus.
Most of you will know what a placebo is or does; it is a pretend treatment (or a real medicine) that has an effect that is beyond the imminently explicable.
If I give you an Ibuprofen tablet and it relieves the pain from your sprained ankle, that drug will work in two ways; the first, will influence biochemical pathways (too complicated for me to understand) that reduce the rate of blood flow to the injury, making the levels of cellular chemicals rise or fall and perhaps even reducing swelling.
This might account for say, and I am making-up this figure, a 30 per cent drop in the pain you experience.
The pill, as it is a pill (or a capsule or tablet) will have an added effect on the pain, perhaps another 20 per cent.
This latter process is little understood, but something to do with the complexity that connects with the way our brains function and, probably, time.
The brain component, is the belief that a pill will help, it affects our perceptions of pain (and pain is nothing but perception – your ankle isn’t sore, the pain is perceived in your brain) and the reality that a more ancient concept is at work – time heals all wounds.
The effect of the Ibuprofen is therefore a mixture of drug effect, psychology/neurology and time.
We still do not understand how placebos work, for example, if I give one person a bitter placebo and another a tasteless one and tell them both the medicine is to relieve pain, the person taking the bitter pill will likely report a greater shift in their symptoms.
This is an explanation for snake oil, cod liver oil and other fake remedy successes. (Barring perhaps Coke or 7-Up back in the day).
I therefore consider treatment with an awareness of the effects of placebos – which says, even though the pill I am prescribing is not helpful, the patient, or often, their relative or carer might believe it is having an effect. (The latter explaining many of the effects of anti-dementia medicines).
This is all OK so long as the pill doesn’t have any major side effects/complications/harms or isn’t too expensive.
And here I have reached my point.
It relates to anti-depressants.
Recently I have discovered that I had, perhaps naively, been caught in the marketing slogans of drug companies, using a reductive medical model of mental health.
You see, if a patient came to see me, or, as is often the case, before Covid, I went to see them, and now, we sort of meet each other half-way on the phone or a video-call, with symptoms of depression – low mood, lack of energy, sleeping too much, too little, worry, lack of enjoyment, perhaps even thoughts of death, with some further questioning relating to the timescale, past history, current situation and so on (applying this to me, my dog Maisie was put-down this week as she had cancer; I am not depressed, just very upset, grieving), and, the diagnosis of ‘depression’ if reached there would follow a discussion as to the best form of treatment.
NICE, the UK’s evidence-based guiding body usually advises as a first-line, talking therapy; called ‘IAPT’ – which is short for, ‘Improving Access to Psychological Therapies’, this is the process of meeting a councillor and having a number of sessions to address underlying problems in more detail that a doctor is able and, potentially to begin some (talking) therapy, usually, nowadays, CBT, Cognitive Behavioural Therapy.
This works well.
As suggested above, many who are depressed recover spontaneously, some require support and others need more.
It is the need-more group that I am discussing.
You see, in medicine, and I know I am not alone here, having spoken with many colleagues, and, this is a commonly held belief, there is a tendency to conceptualise depression as being a physical disorder – this says that what is wrong is not, you, ‘You might be depressed, the problem isn’t you, it is chemicals, and, in particular, a neuro-transmitter serotonin (alternatively known as 5-hydroxytryptamine, or 5-HT).
‘Depression is caused by the levels of serotonin in your brain being too low,’ Or, perhaps, if you want to look like you know what you are saying, ‘The neuro-receptors in your brain for the ‘happy’ chemical serotonin are not receiving adequate stimulation,’ And, words to that effect.
‘Fear not,’ You say, and, ‘This may sound ‘mental’, It is instead physical, you need something to redress the balance, voila, SSRI…’ SSRIs – Selective Serotonin Reuptake Inhibitors, released to the public in the 1990’s are the biggest selling drugs in the world, with the biggest profits, the greatest advertising and, the least proof of effectiveness.
Many doctors over the years will have used the diabetes analogy to somehow make depression more palatable, reflecting not a disorder with the person or their situation or life experiences, but more a breakdown in the machinery, ‘It’s like diabetes (Type 1), where your pancreas doesn’t secrete insulin, all we need to do is sort that and you will be fine,’ or, similar. ‘Oh, and, as it is like diabetes, there is a chance you will have to take the medicine for the rest of your life,’ and, ‘Yes, I know you are 30 years old.’
I have most of this up, although components surface in doctor-patient conversations every day.
And, in all honesty, this was, to a greater extent my understanding; that was until I recently discovered the work of Irving Kirsch (no relative, as far as I am aware) and others, into the effect of placebos and the whole industry that is the medicine-pharma complex; the manipulation of doctors and their patient’s fears by multinational drug companies, who over the past 50 years have indulged in cover-up, mis-representation, lies, trickery and data manipulation to create a situation where today there are five times the numbers of people experiencing depression, anxiety, bipolar disorder and schizophrenia than there were 80 years ago. (There is a much smaller increase in developing countries, not because of underdiagnosis, but less access to medicines with potential long-term effects on mental health and wellbeing).
I don’t (or can’t) go in to all the details here – and, I am definitely not saying that schizophrenia or ADHD, Social Anxiety or Borderline Personality Disorder do not exist – this would be absurd) (although, ADHD, SA and BPD did not actually exit before the 1980s), more, the drug companies, and, for the better part, the psychiatrists in America have spent decades manipulating what has become described as a, ‘mental health crisis’ based on the sales of pharmaceuticals.
I am getting off track a little, and essentially, I wanted to re-wind and explain, that the evidence suggests that many of the pills people take for mental health disorders work no better than placebo;
This doesn’t mean to say they do nothing, rather, they do something, but the way they do it is contrary to the popular narrative.
Those who are depressed do not have high or low levels of serotonin; this is a myth. SSRI’s do increase the level of Serotonin in the brain, yet, as to the effect of this elevation on depression, we don’t know.
Indeed, it appears one of the effects of SSRIs while increasing the levels of Serotonin is to reduce the numbers of receptors for these molecules, which creates a status quo where although there is more Serotonin in the central nervous system it is no more effective than before starting of the drug.
This is not to say that SSRIs are benign;
They exert effects, with reduction in brain receptors for Serotonin, which result in long-term requirement for the drugs, for, stopping them – especially if suddenly (and this is NOT something I am advising without the support of a doctor) is a Serotonin deficiency state that can result in a significant worsening of depression (as the relative levels in the brain drop significantly).
You might call it a mess.
Sure, the pills help, but their help is Faustian.
It guarantees the pharmaceutical companies ongoing income.
I appreciate I began discussing the differences between doctors and surgeons; an old advisor of mine used to describe us, that is physicians as shamans; it was the dance, the performance that helped the cure or the improvement (that and time and perhaps effective antibiotics), unlike the surgeons who would cut-out the offending organs or abnormality.
I have always accepted this concept; it has taught me humility.
It has shown me the limitations of my actions, where I take an approach of considering whether the drug I have prescribed is more a function of my ego, ‘I prescribed that medicine that made you better,’ or just time, luck or fate, ‘You would have recovered without anything I have done.’
It is very easy to fall into a system of beliefs that represent what we want to imagine to be true;
Much of this relates to our primitive psychology; we see the storm, the earthquake or disease and believe that our actions or inactions have led to the forces of nature turning against us, sweeping down and expressing their vengeance.
The sense of our helplessness becomes unbearable.
Alone in the world, it is easier to imagine the doctor is able to write a prescription that will help, when we realise the power to heal or improve, within certain constraints (we can’t cure cancer or heart disease spontaneously) is within us.
I mentioned earlier that my dog Maisie died this week.
Six weeks ago, she stopped eating dried food.
I couldn’t understand why, as this had been her staple.
I bought liver and heart and cooked-up a pasta-grain mix; even when the supplies of pasta were low.
This she ate.
Yet, something was different.
She still energetically, enthusiastically bounded around the house; she barked when the postman called, ran to greet me or anyone arriving at the front door, she would scamper, rat-a-tat across the laminate flooring, the tempo related to her level of excitement, often a reflection of her sense that we were going a walk.
All I needed to do was pick up my earphones or walk in the direction of my boots and she would know.
We had not accessed the vet because of Covid and, her vaccine was overdue.
We mentioned to the vet her changed appetite, some episodes of vomiting.
‘It’s a mass,’ He said.
We briefly discussed the options and she had a blood test.
We received the results on Thursday, she had a CT on Friday.
By mid-day the vet was injecting a yellow chemical into the vein in her leg; we were allowed to spend some time with her in the car park, as she lay unconscious on the trolley.
And then she died.
I buried my face in her fur and could only smell anti-septic.
Tuesday, I thought she was under the weather, Friday no more.
I can still hear her footsteps; I expect her to burst into my bedroom in the morning at the first sign of my stirring.
Six months ago she learned how to let herself out of my bedroom, scratching at the handle and somehow pulling the door towards her.
We have washed her bowl and her basket, put them away.
We are stunned.
Living though an unreality.
She was eight and a half;
We rescued her from a Shelter in Barnsley when she was six-months old.
A crazy dog at first, resistant at times to even the charms of Neil Losada and his dog-training skills, over the course of months and years she became part of us. Alongside us for trips to Scotland. Dunoon, Orkney, Eigg; beautiful images as she looked out on fields and scampered over rockpools.
She would sometimes howl with glee before a walk, marching on the spot, tail wagging.
Wigwag we called her.
She was Nana from Peter Pan.
And now she has gone.
I am sorry we couldn’t have spent more time together Maisie.
I value the hours we spent discovering that back paths and tracks around our house.
Last week, despite advanced cancer, we walked for 90 minutes, exploring a new route.
She sniffed a little more than normal, this I now realise was her breathlessness and she peed more – the tumour pressing on her bladder; she only had half a bowl food when we returned, although she finished the rest a little later.
As to whether Maisie ‘knew’ she had cancer, I am sure she sensed something wasn’t right.
Her final night, she lay on the floor beside my bed.
A year ago, I noticed that Maisie’s behaviour had changed. I described this in a blog.
At that time, I wondered whether she might be sick.
Instead, I realised it was me who had been ill; recovering from many months of depression and anxiety I felt myself returning to normal.
It wasn’t my serotonin levels, but the situation at work, and with this shifting, life returned, and so too did Maisie;
She was less around, she was more relaxed, in tandem with my return to normality.
I miss her, we all miss her.