To Tell the Truth

A new internet-based survey of 2,020 patients who had received treatment for depression, conducted by a Dr. Sawada and presented at the Annual Congress of the European College of Neuropsychopharmacology, revealed something that I have known about for a very long time.  A lot of patients lie to their doctors. 

About 70% admitted lying at least once!  66% stretched the truth about daily activities such as work while almost 53% were untruthful about their symptoms - on purpose.

That patients can be less than honest should come as not surprise to anyone familiar with the literature on patient compliance with doctors' orders.

In the United States, according to some estimates 20-30% of prescriptions are never even filled at the pharmacy.  According to the World Health Organization, only 50% of people complete long-term therapy for chronic illnesses as they were prescribed. According to the US government's Office of the Inspector General, research indicates that 55 percent of the elderly do not follow the medication regimens prescribed by their physicians.

As described in my post of August 10, 2010, Don't Ask, Don't Tell, I  had an exchange with another psychiatrist that included the following:

Me: Family members will not usually volunteer the whole truth during a superficial visit with a doctor. Anyone who thinks that family members act the same way at home as they do in front of an authority figure, or that they will be totally honest about things like family violence or abuse, needs to get out more.

Other Psychiatrist : This broad statement essentially implies and equates pediatric mental disorders with the family abuse and neglect... The reasoning goes along the line "if child has problems, someone in the family caused them." And if the family does not offer any evidence of maltreatment,they are lying. A fundamental fallacy, in my opinion, that for decades prevented psychiatrists from understanding the nature of mental disorders... Suspecting family members of hiding "the whole truth" is a regrettable statement from a professional. 

It sounded to me like it is the writer who is saying that poor discipline or even child abuse is never an issue in any behavior or psychiatric problem at all! And apparently he believes patients never fib or hide information! And the statement about offering evidence of maltreatment?  First, that implies that this psychiatrist probably never even asks about it in the first place but waits for the parents to "offer" evidence. And since we were talking about children, if the parents had been abusive or neglectful, does anyone think that they would admit this to someone who was legally required to turn them in to the authorities?  REALLY?!?

I pointed out in that last post: Obviously this psychiatrist has never done any serious psychotherapy, or he would know that a patient may not reveal absolutely essential information about their situation until they have been seeing a therapist for months.



I've gotten into similar argument with folks who are against psychiatric meds and who demonize antidepressants and mild sedative/hypnotics by telling tales of people they talk to who claim to have had horrible and never-ending side effects from these drugs.  While some of the people such folks talk to undoubtedly did have very bad reactions to the drugs in question, many are also taking other illegal drugs and/or a concoction of several different prescribed psychiatric and/or somatic medications.

More importantly for purposes of this discussion, they may be scapegoating the drugs for personality and family problems that are the real cause of their "side effects." 

When I make the latter point, the usual response I get is something to the effect that "I've met plenty of people who have none of the additional issues you are talking about."  My answer: And you know this how? Do you think people just advertise all the things they are ashamed of and brag about family dysfunction?

Going back to survey that is the subject of this post, the reasons that the subjects gave for not being truthful to their doctors were very instructive.  Although males often withheld or altered the facts due to a fear that the doctor would recommend that they take sick leave or quit their job, the two most common reasons given for lying to the doctor were:

1. The patients found it difficult to talk to their doctor, particularly about things they were ashamed of or embarrassed about (49%).
2. They thought that the doctor would not take it seriously, even if they they told him or her (36%).  In particular, females said they could not trust their doctor or that "he looked busy."

Both of these reasons concern relationship issues between doctor and patient.  For want of a better term, they concern a doctor's bedside manner.  In therapy circles, these issues are referred to as the therapeutic relationship (or as transference and counter-transference, respectively, if the patient and doctor are reacting to one another subconsciously).



In my experience, A doctor - particularly a psychiatrist who must deal with a lot of skeletons in closets - who is not in a rush, who appears empathic and non-judgmental, and who does not seem uncomfortable with highly emotionally-charged or typically squirm-inducing subjects, is far more likely to get the truth out of a patient than one who lacks these qualities.

If the psychiatrist sees the patient frequently in psychotherapy and maintains these qualities, more of the truth will emerge from the patient.

Many of today's psychiatrists only see patients for a few minutes (thereby appearing to be "busy"), and are only interested in the patient's symptoms and not in the environmental and psychological context in which those symptoms take place).  One can safely assume that in many cases such doctors are getting a highly-distorted picture of the patient's clinical condition.

These problems are magnified in randomized controlled drug studies (RCT's).  In such studies, diagnostic interviews and self-report instruments focus only on symptoms and researchers do not even bother to take a psychosocial-relationship history from research subjects. 

Furthermore, researchers do very little to establish a trusting therapeutic relationship with their subjects.  Many do not know how to establish this type of relationship, but even if they did know how and really wanted to try, doing so would increase the placebo response rate and should therefore not be done in a so-called empirical study!

Since they are not based on lab tests, the data from these studies is almost all dependent on the truthfulness of the subjects, which as I have been arguing is highly questionable in many cases. When lab values are available, such as blood levels of such drugs as lithium, depakote, and tricyclic antidepressants, they are seldom checked frequently if at all. 

And even if they were, they are still subject to manipulation by the research subjects.  Most drug levels should be so-called trough levels - the lowest level that a medicine is present in the body over a 24 hour period.  Levels should generally be drawn 10-12 hours after the last dose of the medication taken and before the next dose is taken.  All a patient has to do to appear to be taking the drug more often than he or she actually is is to take a dose just prior to the blood draw.

This is another big reason why randomized controlled studies should NOT, by themselves, be the gold standard of so-called "evidence-based" psychiatry.