Such Mixed Feelings About Crazymeds

Crazymeds.us is an excellent and highly informative site which I will never recommend to my patients.

It’s excellent because it gives mostly accurate and readable descriptions of the costs and benefits of every psychiatric medication. It has a laser-like focus on what patients will actually want to know and was clearly written by someone with an encyclopaedic knowledge of every treatment’s strengths and potential pitfalls.

This is important because the standard psychiatric response to someone who wants to know about a medication (when it’s not “shut up and trust me”) is to print out an information sheet from somewhere like drugs.com or webmd.com. These sites at worst just copy paste the FDA drug information sheet, and at best list off side effects in a rote and irrelevant way that only a robot could love.

Here’s an excerpt from drugs.com about the side effects of Prozac:

Get emergency medical help if you have any of these signs of an allergic reaction to fluoxetine: skin rash or hives; difficulty breathing; swelling of your face, lips, tongue, or throat.

Report any new or worsening symptoms to your doctor, such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

Call your doctor at once if you have:

– blurred vision, tunnel vision, eye pain or swelling, or seeing halos around lights;

– high levels of serotonin in the body–agitation, hallucinations, fever, fast heart rate, overactive reflexes, nausea, vomiting, diarrhea, loss of coordination, fainting;

– low levels of sodium in the body–headache, confusion, slurred speech, severe weakness, vomiting, loss of coordination, feeling unsteady;

– severe nervous system reaction–very stiff (rigid) muscles, high fever, sweating, confusion, fast or uneven heartbeats, tremors, feeling like you might pass out; or

– severe skin reaction–fever, sore throat, swelling in your face or tongue, burning in your eyes, skin pain, followed by a red or purple skin rash that spreads (especially in the face or upper body) and causes blistering and peeling.

Common fluoxetine side effects may include:

– sleep problems (insomnia), strange dreams;
– headache, dizziness, vision changes;
– tremors or shaking, feeling anxious or nervous;
– pain, weakness, yawning, tired feeling;
– upset stomach, loss of appetite, nausea, vomiting, diarrhea;
– dry mouth, sweating, hot flashes;
– changes in weight or appetite;
– stuffy nose, sinus pain, sore throat, flu symptoms; or
– decreased sex drive, impotence, or difficulty having an orgasm.

This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

If I ask a patient to read this, one of two things happen. First, they read the first few sentences and are like “Sure, whatever, I’ll read it when I get home” and then throw the paper in the trash can on the way out of the room. Or second, they get to the part where it says “agitation, hallucinations, fever, fast heart rate, overactive reflexes, nausea, vomiting, diarrhea, loss of coordination, fainting” and they’re like WHAT ARE YOU TRYING TO GIVE ME I’M NOT TAKING THIS GARBAGE!

Here’s crazymeds.us on the same topic:

4.1 Typical Side Effects of Prozac (fluoxetine HCl)

The usual for SSRIs – headache, nausea, dry mouth, sweating, sleepiness or insomnia, and diarrhea or constipation, weight gain, loss of libido. Most everything will go away after a week or two, but the weight gain and loss of libido might stick around longer. Or permanently. Although weight gain is a coin toss.

4.2 Not So Common Side Effects of Prozac (fluoxetine HCl)

Rash, ‘flu-like symptoms, anger/rage.

4.3 Prozac (fluoxetine HCl) Freaky Rare Side Effects

Bleeding gums, amnesia, anti-social reaction (oh, come on, like we’re not anti-social already), herpes (again, blaming the med for an STD), excessive hair growth, engorged breasts (a.k.a. porno boobs), involuntary tongue protrusion (according to the PI sheet / PDR one 77-year-old woman stopped sticking her tongue out at everyone after they stopped giving her Prozac (fluoxetine hydrochloride)).

This is readable, complete without being overwhelming, gives you a good idea how likely everything is, and, dare I say it, funny. It tells you which things to expect, how long to expect them to last, and even mentions that they’re “usual for SSRIs”, which is pretty important for someone using the side effects to decide whether they want to take Prozac vs. another drug.

I also am eternally grateful for them mentioning how some people blame the medication for their STDs – the FDA has this thing where if someone reports something they take it seriously, and it ends up with drug leaflets including anything that’s ever happened to someone while on a drug as a “possible side effect” (“My pet turtle died when I was on Prozac, I demand you warn customers that one side effect of Prozac is ‘increased mortality for associated chelonians’!”) Crazymeds.us calls them out on this.

Everything crazymeds.us does is like this. Well-written, funny, mostly accurate (with the occasional mistake but no more than you’d expect from an individual effort), and precisely targeted to what patients really need to know.

And I still don’t recommend it to my patients, and probably never will. Why not?

Well, for one thing, it’s called crazymeds.us.

Most psychiatric patients have no problem with the word “crazy”. Either they don’t think of themselves as crazy, or they jokingly call themselves crazy and are happy to let other people in on the joke, or they self-identify as crazy as matter-of-factly as they’ll tell you the time of day, or they just don’t care.

But some psychiatric patients care about it a lot. Either they’re moderately neurotic people who are scared that if they accept psychiatric help with their mild depression it puts them in a category of “total lunatic” from which they will never escape, or they’re social justice types who are watching like hawks for any sign that their psychiatrist is a privileged ableist oppressor trying to use slurs to trivialize their concerns and victim-blame them for their problems.

I can usually tell which category a given person is in pretty quickly, but the chance of accidentally slipping up and recommending to someone from the second category a site called crazymeds.us is too horrible to contemplate.

And it’s not just the name. Somebody is going to say that the reference to “porno boobs” is objectifying women or trivializing the problems of people with gynaecomastia. Someone will point out their misuse of the term antisocial and their seemingly flippant dismissal of social phobia. Someone will definitely have something to say about the issues raised by selling crazymeds-brand mugs saying “Medicated For Your Protection”. This isn’t just a couple of slipups here or there. It’s the entire ethos of the site.

Alyssa Vance introduced me to the idea of “negative selection”. It’s when you don’t care how good something is, you just want it to definitely not be bad. For example, when you’re hiring fast food workers, you’re not looking for someone with a Harvard degree in fast foodology who will revolutionize what it means to work at McDonalds for generations to come, you just want someone who you’re really sure isn’t going to show up late or commit any crimes.

Likewise, medicine involves some heavy negative selection. If I become the best, most likeable, most respectful, most intelligent psychiatric resident in the country – well, I’d still get paid exactly as much as I do now. On the other hand, if even one patient lodges a complaint against me – let alone a lawsuit – that’s probably a hospital investigation and a stern talking-to from my boss and his boss and a discussion of why a site called crazymeds.us talking about how psych patients are “Medicated For Your Protection” is Not Appropriate and really you’re a second-year resident shouldn’t you know things like that already maybe you need some Remedial Communication Skills Classes.

Side effects of crazymeds.us may include agitation, aggression, and job loss. I think I can predict pretty well which patients will and won’t appreciate this kind of message, but all I need is one misclassification to get screwed over. So, with apologies to the many patients who could be helped by something like crazymeds.us, I’m giving this particular minefield a wide berth.

Part of me wants to grab whoever made the site and scream at them “WHY? WHY ARE YOU DOING THIS? YOU COULD HAVE BEEN BY FAR THE BEST PSYCHIATRIC RESOURCE ON THE ENTIRE INTERNET, IMPROVED THE LIVES OF TENS OF THOUSANDS OF PEOPLE, AND YOU THREW IT ALL AWAY FOR SOME STUPID JOKES.”

But there’s also a part of me that accepts they probably have their reasons. I’m not sure it’s possible to make a site as good as crazymeds.us without it being as offensive as crazymeds.us. Remove every single flippant statement and optimize for complete unobjectionability, and you’re most of the way back to drugs.com. I mean, there are certainly some simple improvements that could be made on drugs.com, and there’s probably a market for a site like that, and maybe that site already exists and I just haven’t found it. But crazymeds is something special. It’s inspiring trust through countersignaling. In a field where almost everyone is a dry, scientific person who won’t give you a straight answer about anything or treat you like a human being, crazymeds’ business strategy is to make it super obvious they’re the exact opposite of that. They’re human, and I think that’s precisely why a demographic who wouldn’t trust anybody else trusts crazymeds.

Athrelon writes about social technology, structures and institutions that allow the maintenance of trust and order with a minimum of fuss. Crazymeds is an item of social technology that draws people who would normally be unwilling to learn about the psychiatric system into an engagement with it and an ability to understand and manage their own care.

Athrelon also writes about the breakdown of social technology in the face of certain modern social norms. And I talk a lot about “political correctness” and so on. And one retort I sometimes get is “political correctness just means being nice and not going around offending people. How could you possibly be against that?” And I have had vague feelings that it probably does something bad and have just mumbled something about how I’d look for an example and let you know when I found one.

Well, this is an example. I’m pretty sure there are a lot of people who would benefit from crazymeds, or at least from straighter talk than the carefully hedged neutral statements on drugs.com, or at least from a little bit of humor or conversation in a register associated with normal healthy human relationships – but as long as I’m not 100% certain no one will be offended, and as long as that one offended person can cause me more grief than the hundreds of satisfied customers can possibly make up for, I’m going to keep printing drugs.com handouts, and explaining while mentally facepalming that no, the hallucinations and agitations don’t happen to everyone.

On the other hand, you guys have taken much worse from me and I’m still here, so I recommend it to you without hesitation. Obvious caveats (eg don’t do anything without talking to a doctor first) are obvious.