From the Editor
A psychiatrist/lawyer crossfire
A friendly debate lays to rest lawyers’ misconceptions about psychiatry
Do lawyers understand psychiatry? To answer that semi-rhetorical question, I imagined the following conversation between 2 friends, Barry the barrister and Harry the psychiatrist.
Barry: Harry, I think psychiatry is a politically incorrect discipline.
Harry: How so, my dear friend?
Barry: Well, psychiatrists hospitalize people against their will, strip them of their civil liberties, and force them to take powerful, mind-altering drugs.
Harry: Barry, when you think about it objectively, involuntary hospitalization is a compassionate and legal act for people suffering from a brain disease that makes them suicidal or homicidal and a danger to themselves and others with no insight that they are sick. Once treated and improved, patients regain their civil liberties and often thank us for providing care against their will. And a person needs a healthy brain to properly exercise one’s civil liberties.
Barry: What about electroconvulsive therapy (ECT)? Why would you subject people to such a primitive procedure?
Harry: For your information, when used for treating severely depressed persons who do not respond to multiple medications, ECT is one of the most effective procedures.1 It saves the lives of suicidal patients and restores their functioning. Published studies show that ECT stimulates neurogenesis and helps regenerate brain tissue by stimulating the production of new brain cells in the hippocampus, a critical structure that loses tissue during depression.2 Other neurostimulation techniques, including repetitive transcranial magnetic stimulation (rTMS) and vagus nerve stimulation (VNS), recently have been FDA-approved for severe depression. Deep brain stimulation (DBS) also is emerging as a promising treatment.3
Barry: But Harry, you psychiatrists medicalize normal emotions such as sadness or grief and pathologize high energy in children, transforming them into diagnostic labels like attention-deficit/hyperactivity disorder.
Harry: Normal sadness or grief is not a psychiatric diagnosis. People seek psychiatric help on their own or are brought in by their loved ones when an emotional tsunami devastates their lives, causing them to stop functioning, demonstrate unusual behavior, or express suicidal thoughts. Children referred for treatment because of uncontrollable behaviors at home and school are afflicted by neurobiologic disorders and FDA-approved medications help them to lead normal lives. Do you really believe children are incapable of having a psychiatric illness?
Barry: OK, but isn’t it irresponsible for psychiatrists to administer powerful antipsychotics to elderly persons in nursing homes when the FDA has issued a “black-box” warning that this practice may be fatal?
Harry: I wish that one day you would visit a facility for older persons with Alzheimer’s disease to see that as many as half of these individuals become psychotic, extremely agitated and assaultive, or a risk to themselves, the staff, and other patients.4 Would you like to advise physicians about how to manage serious dementia-related delusions and hallucinations without using antipsychotics?
Barry: You keep throwing the ball in my court, but psychiatrists violate the law daily by using psychiatric medications for conditions other than their approved use. Some studies show that up to 60% of psychotropic drugs are being used off-label.5
Harry: Less than 20% of DSM-IV diagnoses have an FDA-approved medication.6 What do you expect psychiatrists to tell the other 80%—“Sorry, come back in a decade or 2 when a drug is finally developed and approved for your condition”? Psychiatrists are compassionate when they select a medication the FDA has already deemed safe for a certain psychiatric illness and prescribe it for other ailments that have some of the same symptoms. Thanks to judiciously implemented off-label practices, many patients obtain some relief instead of continuing to suffer. And there is no law against off-label prescribing. It is left up to the physician’s discretion to use existing tools when there are no other options.
Barry: Harry, your responses have led me to view psychiatry more positively. I urge you write an editorial in a legal journal to debunk the myths.
Harry: Thanks for the suggestion, Barry. I think I will write an editorial in a widely read psychiatry journal called Current Psychiatry and avail it to all attorneys via CurrentPsychiatry.com.
1. Fink M. Electroconvulsive therapy. 2nd ed. New York, NY: Oxford University Press; 2008.
2. Bolwig TG, Madsen TM. Electroconvulsive therapy in melancholia: the role of hippocampal neurogenesis. Acta Psychiatr Scand Suppl. 2007;433:130-135.
3. Kuhn J, Gründler TO, Lenartz D, et al. Deep brain stimulation for psychiatric disorders. Dtsch Arztebl Int. 2010;107:105-113.
4. Chahine LM, Acar D, Chemali Z. The elderly safety imperative and antipsychotic usage. Harv Rev Psychiatry. 2010;18(3):158-172.
5. Chen H, Reeves JH, Fincham JE, et al. Off-label use of antidepressant, anticonvulsant, and antipsychotic medications among Georgia medicaid enrollees in 2001. J Clin Psychiatry. 2006;67(6):972-982.
6. Devulapalli K, Nasrallah HA. An analysis of the high psychotropic off-label use in psychiatric disorders: the majority of psychiatric diagnoses have no approved drug. Asian Journal of Psychiatry. 2009;2:29-36.