Tuesday, March 03, 2015

Big Girls Don't Cry. Take a Pill.

Updated for typos!
In Sunday's New York Times there was an interesting article by Dr. Julie Holland about how women's emotions should be appreciated and not pathologized.  

First, let me tell you that I read Dr. Holland's book called Weekends at Bellevue and I hated it.  She talked about her sadistic feelings (and sometimes actions) towards patients, and her own therapy to overcome this.  While I realize that we don't all harbor the kindest feelings towards every single patient on every single day, and sometimes docs have rough stuff going on too, I was appalled.  She whistled some song about here comes the parade when prisoners were brought into the ER.  She was mean and disrespectful.  Feelings are feelings, but to knowingly be sadistic and disrespectful to patients is inexcusable. I read it and was embarrassed to be a member of her profession. 

Now that I got that off my chest, the article in Sunday's NY Times called Medicating Women's Feelings was interesting and thought-provoking.  Holland writes:

WOMEN are moody. By evolutionary design, we are hard-wired to be sensitive to our environments, empathic to our children’s needs and intuitive of our partners’ intentions. This is basic to our survival and that of our offspring. Some research suggests that women are often better at articulating their feelings than men because as the female brain develops, more capacity is reserved for language, memory, hearing and observing emotions in others.

These are observations rooted in biology, not intended to mesh with any kind of pro- or anti-feminist ideology. But they do have social implications. Women’s emotionality is a sign of health, not disease; it is a source of power. But we are under constant pressure to restrain our emotional lives. We have been taught to apologize for our tears, to suppress our anger and to fear being called hysterical.

Dr. Jeff Lieberman, the past APA president tweeted that the article was 'anti-psychiatry.' I didn't see it that way at all.  Holland talks about how anti-depressants clearly help some people, but she also discusses the high numbers of women who are treated with them.  It's an issue we've  discussed many times here on Shrink Rap:  our illnesses are syndromic, they are decided by committees (with the help of research), but they can be inexact.  Say you need 5 symptoms for 2 weeks to meet criteria for depression, and a patient comes in with only 3 symptoms for 10 days, but those three symptoms include profound sadness, suicidal thoughts, and a loss of appetite, I don't believe too many psychiatrists are going to stand there with a check-list saying, nope, you need 4 more days and 2 more symptoms before we can call it depression, come back then.  

Was the article right?  Was it just plain sexist?  Are women moodier than men and is treating this a form of suppression?  I am certainly moodier than my husband.  But everyone I  know is moodier than ClinkShrink and she's a woman.  Should we accept and celebrate, depression in women, but not in men?  Are some people over -diagnosed and over- medicated? Who is to be the  judge of that if a patient says 'Look, this medicine helps me feel better'?  Or are there people who are under-diagnosed and under-medicated?  I suspect the answer is 'All of the Above,' and I still go with the idea that if you show up at my door and say you're suffering, and you want to try meds, I'm usually fine with that. But before you knock, know that I will also insist on therapy, at least at the beginning of treatment.

So I think questioning is fine.  What is the role of the pharmaceutical companies in deciding what's an illness and what we treat?  Do we under-diagnose or over-diagnose?   
Emotions occur along a spectrum and they come and go over days or hours if not weeks or months.  It's not anti-psychiatry to be skeptical or to question.  And debilitating mental illness is not subtle. I do believe it's the subtleties, the symptoms that come and go in someone functioning normally that Holland may be talking about.  

What do you think? 


Steven Reidbord MD said...

I agree Holland's article was interesting, thought-provoking, and not "anti-psychiatry." I'm not familiar with her other writing, so I can't tell whether she's making a general case for letting people experience their natural feelings — similar to the argument Allen Frances makes in Saving Normal — or whether her focus is more strictly on females being judged by male standards.

While I certainly see a role for medicating severe mood states, Holland's example of trying to understand crying at work instead of medicating it away rings true. Feelings tell you something; perhaps the old phrase 'nervous breakdown" gives the false impression that strong feelings indicate psychic damage.

And is it really true that Abilify is the #1 selling drug in the U.S.? Things are much worse than I imagined.

Anonymous said...

I read the book, too, had the same thoughts. I also once sat in on psychiatric nurses giving report, and they had the same contempt and disrespect for patients. I was disgusted. If people are burned out, they need to leave and find something else to do.

One of the things that finally convinced me to see the psychiatrist I see now is that my therapist told me that she has referred numerous patients to my psychiatrist over the years and not one time had he ever made a disparaging comment about a patient, no matter what the patient's challenges were. I think it says a lot about him that he has been doing this for so many years and still has such respect for patients. Unfortunately, doctors like Dr. Holland are out there, and patients know that they are not respected. I guarantee you patient know when they are not respected. I the reason so many of these types end up working in inpatient psychiatric care is that they can't build a private practice. Who would pay to see a doctor like that? Not me. I would never be that desperate.


clairesmum said...

I think the true root of the issue is that compromises made in the past between professional groups and businesses (insurance, hospitals, pharmacology, etc) solidified a false dichotomy between 'substance abuse/dependence' and 'mental illness', and allowed 12 steps to monopolize one area and pharmacology the other one. Non 12 steps resources for addiction and psychotherapy (in its' many forms) are not covered by insurances, or not reimbursed very well to providers. So the best providers stop billing insurances directly. It's become another area where the gap between 'the wealthy' and 'everyone else' is widening. This gap also continues the stigma, as 'the wealthy' can purchase services privately and leave minimal records of diagnoses and treatments by paying cash. The question of gender roles in diagnoses and treatment is a red herring, to me. It's an easier issue to argue about as it can never be resolved, and it perpetuates the 'either/or' thinking that has been so harmful.

jms said...


Although somewhat off topic, I am wondering about something related to a comment you made ("leaving minimal records of diagnoses and treatments").

In numerous comment threads on this blog, former psychiatric patients have expressed dismay that their treatment leaves a permanent record that will follow them for life. This worry seems especially strong among those who were hospitalized involuntary, or those who feel that their doctors made inaccurate statements in their notes, and that they will never be able to escape these inaccurate statements, diagnoses, or "labels". I've heard similar sentiments from a friend who was involuntarily hospitalized as well.

Is it actually possible for a psychiatric diagnosis on a medical record somewhere to affect unrelated interactions with other health care providers? Despite all the hype about "electronic medical records", I've seen no evidence that records kept by one doctor ever actually reach the hands of another. My personal experience with (non-psych) doctors is that many of them can't even be bothered to read their own notes, much less notes written by some other doctor somewhere else. One doctor told me that he never even bothers to ask patients for their old medical records, because anything that isn't current is useless anyway.

I might be missing something here, but it seems like a simple matter to simply not tell a new primary care physician that one has received psych treatment in the past. In general, I wouldn't recommend withholding information from one's own doctor, but if one is concerned that a past psych diagnosis will make the doctor ignore legitimate medical problems in the future, it's always an option.

I could imagine that having been involuntary hospitalized could raise insurance rates, but I don't recall ever seeing as insurance quote form that asks about past psychiatric treatments.

It's true that past mental health treatment can adversely impact US government and military background checks (such as security clearance investigations). Staying "off the radar" here could be difficult, because even the most trivial of treatments (such as one counseling session to cope with school-related stress) must be reported to the government and judged favorably or unfavorably. This is not an incredibly common scenario though.

Dinah said...

Steve -- I wrote an article on this for CPN http://www.clinicalpsychiatrynews.com/views/shrink-rap-news/blog/shrink-rap-news-the-surprisingly-high-cost-of-abilify/472ef62e2926576257856eb036f8004a.html

Abilify is the 14th most prescribed medication. Synthroid is number one. However, synthroid is cheap and Abilify costs $29-$42/pill making it the highest grossing drug.

Steven Reidbord MD said...

Dinah, Now that you mention it, I read and even commented on your CPN article back when you posted about it here on Shrink Rap. I was shocked by the cost per pill. But somehow it didn't register that it was the highest grossing drug in the U.S., even though you plainly said so. It's incredible that this "distinction" belongs to an anti-psychotic.

Anonymous said...


Just a comment about your off-topic comment: I agree with you that anyone concerned about bias could just leave that info out (though it may not be a good idea) but I had a patient with bipolar disorder who had no trouble renewing his security clearance despite the diagnosis. I filled out forms once a year -- I had to say that I did not believe he was a risk to the the US Govt and I'm guessing some docs wouldn't be willing tot say that.

clairesmum said...

If you take medications that are psychiatric in nature, hiding those from your primary care provider and specialists can hinder good medical care. The bias against people with chronic mental illnesses often means that reports of vague sx are viewed as related to anxiety or depression or delusion. If a clinician already has an idea of the cause of a symptom, it influences the assessment of the patient. You look for what you expect to find...and if you assume that there is not a 'real' cause for the sx, you miss stuff. It's one of the reasons why many women prefer to get medical care from female providers, in the hope that you won't be dismissed out of hand. I'd like to think such bias would have faded away by now...but it has not. Using a psychiatric diagnosis as a label is a way to make the person 'other' - not as valuable, or deserving of resources. It is rarely so blatant as to be obvious, but if you work in health care you know it happens.