Thursday, August 23, 2012

Informed consent: 20 questions you should ask the doctor

Adam B is the father of two sons who are currently on psych meds. (He is struggling to get his sons off them.) Recently he shared his excellent advice to the ISEPP discussion forum about the questions people should ask to obtain informed consent when psychiatric drugs are being recommended. I have Adam's permission to reprint  his advice. Please disseminate his questions widely.

Adam writes:

I am of the opinion that better decisions regarding psychotropic drugs being given (or not given) would be achieved if proper "informed consent/informed dissent" processes took place.  Informed consent is a process, not just a piece of paper the Dr. tries to get you to sign to cover his/her behind.You must insist on being respected as a loving and caring parent.

To the extent your rights are being honored, I suggest a serious informed consent/dissent dialogue between you and the Dr.  I also suggest you not sign anything until such dialogue has been taken place and your parental rights are being honored.  To the extent your rights to consent/dissent are being violated, I would encourage legal assistance as has been suggested earlier.  In a nutshell, this entails being informed of the pro's and con's of the proposed treatment (use of drugs) as well as the pro's and con's of alternatives.  Specifically it includes some tough questions that the Dr. may not be able to give acceptable answers to. 

Questions you may wish to consider:
  • What is your diagnosis and more importantly what is the underlying cause?
  • What has been done to rule out medical explanations?
  • What adverse events are known with the use of this medication?
  • What side effects are known to take place?
  • What is the rationale for using this drug?
  • Discuss the science behind the answer to the above.
  • Is the proposed use of this drug off-label? 
  • If off-label, what science are you relying on in terms of its efficacy and safety?
  • How efficacious is this drug short-term?  Long-term?
  • What is the exit plan for this drug? 
  • How long do you intend on using it?
  • Is this drug addictive? 
  • Are there known problems tapering/withdrawing?
  • What effect does this drug have on developing brains?What effect does this drug have on DNA?What effect does this drug have on the endocrine system?
  • Would you give this drug to your child?
  • What are this drug's long-term effects.
  • In regards to any of the science discussed above, discuss the independence, or lack therof, with the pharmaceutical industry.
  • What alternatives should be considered and what are their related risks rewards, efficacy, costs, etc.

To expand on the first and second questions.  Often there is a medical cause for a psychological symptom.  For example, hypo-thyroid can cause depression (I would argue nutritional defficiencies can too).  As someone told me recently, psychiatrists forget they are MD's first.  Meaning in the above example, a good DR. would rule out hypo-thyroidism and other medical causes for depression before even considering using a dangerous drug.  Knowing the cause is paramount to choosing a treatment that does more good than harm.  Differential diagnosis seems to be lacking these days.  Throwing a dart at a page in the DSM is much more fashionable. The greater the difficulty in answering these questions, the greater the absurdity of giving these drugs.  

Imagine the likely response by a psychiatrist to these question compared to that of a surgeon being asked questions on removing an appendix that is about to burst or an orthopedic doctor on the wisdom of setting a broken bone.  The point being is that with the surgeon and orthopedic example, the science is clear, there is no real controversary, no bad science and they really know what they are doing.  The questions will likely be answered with grace and confidence.  In the psychiatrist example, as you know most of many of these very important questions can't even be answered because no one really knows the answer.  The questions that can be honestly answered for the most part will point away from giving the drug.  In contrast, how would we predict the psychiatrist to respond?  With defensiveness or anger or dismissiveness or embarrassment?  Anything but grace and true confidence.


  1. good questions.

    you give surgeons far too much credit, however...much surgery is unneeded and not evidence based either...sadly true.

    Paul was told he needed a serious and life-threatening surgery a couple of years ago (for a back/neck problem). He recovered through natural means. He is fine. The surgery sometimes cripples people permanently.

  2. I agree re good questions and giving surgeons too much credit. We in the psychiatric mire seem to think that surgery (as opposed to psychiatry) is a science, and yet surgery is often needlessly and hastily performed despite the fact there are alternatives available. Adam was careful to restrict his comments to people needing standard emergency intervention (an appendix about to burst or setting broken bone.)


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