Psychiatrists don't know all. Sometimes, they need to defer to patients' lived experiences

As a psychiatrist, I bear witness to a broken system. Mental health care is chronically underfunded, and encounters between patients and psychiatrists are becoming shorter, more sterile, and dehumanized.

When Canadians seek support for their mental health, they are not always welcomed with open arms. Often they are stigmatized, and almost always they are made to wait.

In this context, antidepressant medications have been marketed as a quick fix. Rates of antidepressant prescriptions are skyrocketing, and Canadians are among the world's biggest users of these medications. Antidepressants have become so pervasive that even fish are changing their behaviour because of antidepressant metabolites in our rivers and lakes.

While individual results vary from person to person, antidepressants can be helpful for debilitating symptoms of depression and anxiety. Fortunately, many of my patients with these symptoms get better. Unfortunately though, when time comes to discontinue their medications, things do not always go as planned. The side effects from antidepressant discontinuation can be so severe that may individuals simply keep taking the medication indefinitely.

Antidepressant discontinuation syndrome

A recent study published in The Lancet highlighted that abrupt discontinuation of antidepressants can lead to unpleasant side effects — a conclusion that signalled validation for many patients who have lived the unpleasant experience of antidepressant discontinuation syndrome, which can include nausea, insomnia and sensory disturbances like "brain zaps."

While antidepressant discontinuation syndrome is known to occur in up to 20 per cent of patients, and physicians are encouraged to be aware of the signs, many physicians still taper patients' antidepressants too abruptly, over the course of around four weeks. This study suggests that slower and more gradual dose reduction— over the course of months or even years — may help facilitate successful tapering off of antidepressant medication. That's something that many patients have been saying all along.

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When I reflect on why there is such a stark discrepancy between evidence and practice on antidepressant discontinuation, I cannot help but think of the enduring disconnection between physicians and patients.

Like many of my colleagues, I chose to be a doctor because I thrived on connection. Yet instead of shining brightly, many young physicians are burning out. This is not surprising when medical curricula send us tacit messages to numb ourselves to emotion, lest we be overwhelmed by the suffering of our patients.

A few years ago, I began research to seek a deeper understanding of how patients and health professionals interact with one another. Of particular interest was the discrepancy between intention and action. When we gave feedback to physicians that they might be dehumanizing their patients despite their best intentions, participants shared that receiving this feedback felt like a punch in the gut. Within our professional culture of "excellence," learning that you are anything but perfect is challenging. But if we are all spinning towards disconnection, how do we break the cycle?

Although discourse on "patient-centered" care has become the norm, enacting the concept can be difficult. The rapid democratization of medical knowledge — namely through online access to information — can lead physicians to perceive empowered patients as a threat to their expertise. A popular meme in medical WhatsApp groups and social media riffs off the saying, "Don't confuse your Google search with my medical degree."

Listening to patients

Fortunately, many physicians are pushing back against medical paternalism and antiquated ways of thinking. Perhaps we should reframe the dialogue to be something like: "Don't confuse your couple of hours worth of lecture on antidepressants with my lived experience of taking them for many years."

Truly listening to our patients requires us to step back from clinical dogma and defer to their lived expertise. Improving communication between doctors and patients can actually improve outcomes.

Many physicians are trained within a bygone version of the "medical model," which emphasizes a counterproductive dichotomy between doctors and patients. Yet a number of psychiatrists from my generation are speaking up about shifting toward more holistic, recovery based, and trauma-informed approaches treatment. A future where psychiatrists can be more for our patients is possible, but only if we take the time to reflect on what makes us the experts.

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