Adina Silvestri 0:27
Hello and welcome to Episode 13 of the atheists and recovery podcast. And today’s episode was wide ranging for sure. My guest is Ian Hamilton, and we talk about his latest article in the British Medical Journal about prescription drugs. And although his article is focused on England’s prescription drug problem I would bet, I would bet the farm as they say that the US has a very similar problem as well. Just just for show of hands, funny, right Show of hands- How many of you have someone or know someone who is on depression medication? Mm hmm. Keep them up. And now how many of you know of someone that either abuses that medication? Or perhaps they have been on that same medication for decades? With the same symptoms? And maybe slightly better? But generally the same symptoms? Oh, yeah, look at those hands. Okay. So all kidding aside, guys, I mean, it’s a it’s a serious problem. And so we do value the place of antidepressants, and we value its place, but we also talk about the reasons that people become depressed, and how we as medical professionals help how we, as medical professionals, or mental health professionals, can help can help with with the, with the issue of hope, because it’s, those little pills are not inoculating you from your woes, and they’re not making things better, maybe they’re numbing things out, but they’re not making things better, and so lets move on. So we talk all about that. Okay, and onto my guest, Ian Hamilton is Associate Professor of addiction at the University of York. He is a registered psychiatric nurse and has experience working with people who have drug and alcohol problems. He studies and does research on addiction and writes a regular column on the subject of drugs for Independent newspaper. All right, here, we go

Adina Silvestri 3:13
Ian Hamilton, welcome to the show.

Thank you very much, Adina.

Adina Silvestri 3:19
So I want to start this conversation, as I do most of my conversations by inquiring about your spiritual background. But before we do that, can you tell the audience a little bit about about you? All the way from New York, England today?

Ian Hamilton 3:37
Sure, I’m Associate Professor of addiction, the University of New York. So I spend my working time looking at things like drugs, policy, and problems resulting from drug use. So doing some research, some teaching, and I also work with teams who provide treatment as well. So that’s what I do.

Adina Silvestri 4:01
Good. And talk a little bit about your spiritual background, if you wouldn’t mind from childhood.

Ian Hamilton 4:06
Yeah, of course, well, I guess it will be fairly obvious why I’ve ended up doing what I’m doing now because my father actually had a problem with drugs and alcohol, so and for a number of years, not not while I was around, but prior to me being conceived, he had a problem. And then he had an epiphany. And he became an evangelical minister. So that was my formative years as being around him. And he traveled across the world and preaching. And he also believed he had the gift of discernment and prophecy. So he traveled to Florida to Virginia, mainly up the eastern side of the US, and then over to India and across Europe. And he believed that was his calling. So, you know, in my formative years, that’s what I was exposed to was his various strong and passionate belief in Jesus. And he lived by that belief in that passion, but he wasn’t someone you describe as (I forget the language) Bible pusher, you know, he wasn’t someone who stuffed it down other people’s throats, but you very much, and held that belief and was keen, other should too. So. And I, you know, obviously, I am unfortunate my father’s passed away, and I have a great deal of fondness for him and a great deal of respect for what he believed in, but I don’t share those beliefs. And so I’m, I’m fairly agnostic, really, and and have been since I was a teenager.

Adina Silvestri 5:45
And do you remember that switch from growing up in a fairly religious household to, to making that switch to agnostic, because it’s, for some people, there’s a bit of a loss there.

Ian Hamilton 5:58
No, it felt like that. And I I remember really distinctly because, you know, this was more than just saying, I’m not going back to Sunday school, this as a saying, given the strength of belief, both my mother and father and their friends had it felt like I was pulling away from something. And I still missed that I missed that sense of fellowship, that sense of purpose and belonging, in some ways, but not enough to draw me back into it. So and, you know, I obviously reflect on it. And I’ve, it’s not that I think any less or any more of, particularly of people who have those beliefs, it’s just not for me at this time.

Adina Silvestri 6:37
How did you come to do the work that you do? Can you talk a lot about that?

Ian Hamilton 6:42
Well, I think it was destiny really given more. And my father did you know, he he counseled he obviously did it from a certain perspective, but it certainly had an impact on me. And I think without even knowing it was where I was drifting towards in terms of work in a career really. So something that really interested me is trying to understand how people develop problems, and could I play any role in helping them. So from that point of view, is fairly selfish, you know, I was looking to see how I could get something out of this as it were. So you know, trained as a nurse that seemed fairly logical, a psychiatric nurse or mental health nurse. And as you know, the first thing I did when I qualified was went straight into the drug addiction fields who worked in a drug detox unit or residential unit. And, and over a decade, worked either in the community or in residential settings with people who had drug and alcohol problems. So and I can trace it back, as I say, to my dad, and then, you know, obviously, once you’re an adult, you have to take responsibility. So I can see how it was shaped and why I had that interest. And I’m really grateful to my father and my mother for giving me that interest in that enthusiasm. And to kind of get involved really, in that rather than I don’t know, accountancy or the law, whatever happens to be

Yeah.

Adina Silvestri 8:10
Yeah. So let’s talk about how I how I came upon your, your writing. So I was, I found you on the British Medical Journal. You wrote a piece on prescription drugs and, and how they’re no cure for deprivation. And I thought we could spend some some time talking a little bit about that, because when I look at your work, the other The, the other person that comes to mind is Dr. Gabor Mati when i when i read your writing, and so, and I think that was one of the things that first drew me to you. So maybe we could talk a bit about that.

Ian Hamilton 8:54
Yeah, of course.

Ian Hamilton 8:57
So, I mean, essentially, the the piece that I wrote for the BMJ was, as a result of government report, really, that came out just a couple of days earlier. And this this government report was instigated due to rising prescriptions for drugs that people in the US will be familiar with opiates. So prescription morphine, as well as synthetics like Tramadol, and so on. And but also what’s interesting about this report is included is antidepressants So, Selective Serotonin uptake inhibitors and so things like I don’t know what the names are in the US, but in the UK, we have prescriptions for depression, for things, names like Venlafaxine, fluoxetine, better known as Prozac. And so all this time drugs now that’s to me, that’s quite an interesting combination of antidepressants in amongst opiates, and benzodiazepines like diazepam, you wouldn’t normally associate those two classes of drugs. So that’s what got me interested, really. And, you know, I reflected on it a little bit and then wrote that piece really so just based on my thoughts on what I thought was going on, really, and why this report painted such a clear picture of the link between the rise in prescribing of these drugs. And it wasn’t just that the numbers have increased, but also, the length of time people stay on these prescriptions was the other aspect. And, and another additional factor was they found a link between areas, geographical areas that were socially deprived deemed to be socially deprived and the concentration of these prescriptions. So in other words, geographical areas that were quite affluent had a lower rate of prescribing than areas that were less affluent. And so you could call it class, you could call it social deprivation, call it whatever you like. And basically poor people are prescribed more of these drugs than rich people. That’s what it boils down to.

Adina Silvestri 11:22
Yeah, yeah, that’s, that’s so interesting.

Adina Silvestri 11:27
And so it’s almost like they’re using these drugs in a certain class, or the certain geographic areas to either soothe pain, maybe or distract from it, or what are some things that that come to mind?

Ian Hamilton 11:44
Yeah, I mean, it’s fiendishly difficult to be absolutely sure, I think all we can do is generalize a little bit because we have no way of, you know, when data on whole populations like this comes out, you’ve no way of separating out obviously, person by person. I mean, the first thing to say is, some people and I joined the view, we take the view that actually an increasing rate of prescribing of antidepressants is no bad thing, necessarily, because it might just be that people are getting treatment, which they previously didn’t. So that’s a possibility is we’re just better at identifying people who are depressed and ensuring they get some form of treatment, in this case, a pill. However, I don’t think that tells the whole story. And the reason for that is what this reminds me of is when I started in this field 30 years ago, the first thing I walked into and made a real impression on me was the number of people back in the 1980s and 1990s, who was struggling with benzodiazepine addiction, or dependency. So these were people who had been prescribed diazepam to Mezapam, at any other time you care to mention for very similar things for depression and anxiety, and the effect was that 15 20 25 years on these people, were still taking these pills and in, you know, really high doses and struggling to reduce it. So when I saw this report on antidepressants, there were there was a lot of similarity, I read into it compared to what was going on 20, 30 years ago. And we know know, of course, that Benza as benzodiazepines, pills, of course, are, you know, quite addictive, and some people do have real problems with them. So that’s the other aspect to this is nobody really looked into the dependency potential of antidepressants. And of course, if you don’t look you don’t find. And I think probably what we’ve got here is an early Indication, that there is a problem, and that some people are becoming dependent on these. And I don’t think the pharmaceutical industry has been particularly helpful, they’ve they’ve not provided any input into this any data from early trials. And of course, a lot of the problems with dependency, and don’t come to light for months or years after people are exposed to a pill. And most trials to get approval only last a matter of months at best. And so a drug may well be approved and new dependency issues show up in a pharmaceutical trial. But that doesn’t mean to say dependency is there.

Adina Silvesri 14:43
Yeah, I know, in my, in my practice, I work with individuals that are struggling with substance abuse and eating disorders, but for the individuals that I see a lot of them I’ve been on antidepressants for decades. And I think one of the reasons that they’re reluctant to get off of them, it’s because well, you know, how it’s fear. You know, what, what am I going to replace this with? You know, what if I start to have what if I start to feel the feelings again? And that’s something that comes up a little that is. No, I am, I can’t, I want to mask these feelings I don’t want to feel.

Ian Hamilton 15:23
Yeah, and I think the other aspect to this is if we just concentrate on antidepressants, and the reason that you would be a physician would think about giving you an antidepressant is because you would present with what are called first ranked symptoms of depression. So that could be things like not sleeping well, obviously, your mood being very low, reduction in appetite, and unable to enjoy things, etc, etc. Know that those are symptoms of depression. But those also happen to be symptoms or aspects that are associated with dependency in withdrawal from a drug. So, so when it gets that someone started an antidepressant, and they’ve been on it a few months, and and what physicians are noticing, and patients are complaining of is that when those tablets are stopped, or they’re reduced. And they’re experiencing things like disruption of sleep, and interruptions, and they’re thinking, loss of appetite, loss of hope, and lack of interest. Now, how do you distinguish what is due to the pill and being withdrawn? And what is due to poor mental health? And, you know, answers on a postcard, please, I have no idea how you work that one. And I don’t think you can, you know, I think it’s it’s trial and error. And it’s going to vary by individual. And I think the other aspect to this, I just like to mention is, I’m not sure, as academics and researchers and clinicians, we make this distinction between dependence and withdrawal. So it was apparent in this report that antidepressants were tagged with the phenomenon of withdrawal, but not dependency. To me, that’s a perhaps at best a nuanced difference. And in some ways, I see it as an irrelevant difference, whether you want to call it dependency or withdrawal, I don’t think helps the person experiencing the symptoms. And so I think that’s something we need to address is, in truth, we don’t know whether antidepressants create dependency. What this report strongly suggests is there is a set of withdrawal symptoms that people experience. My argument would be why don’t we call that what it is? That’s dependency, and it’s, whether you call it withdrawal, or dependency. And it’s just playing with words, but I think sometimes words matter. And so to say that, I don’t know a drug like oxy cotton or heroin, you experience both withdrawal and dependency, but for antidepressants, only withdrawal symptoms, seems rather odd to me.

Adina Silvestri 18:19
Definitely.

Right. So that’s, that’s an interesting point. And so do you think that these prescription drugs are, are seen in the same light as cocaine or heroin?

Ian Hamilton 18:33
Absolutely, no, you know, I think anything that is deemed to be coming from, you know, a trusted official route I you by your physician and pharmacist, and we have faith. And I mean, the The other aspect to this, which I think is quite interesting is who has status in all this in terms of who do we believe. So be cause this is the problems people have been experiencing with, with, with antidepressants, and those withdrawal symptoms is something that patients have raised. This isn’t something that doctors and researchers have looked at. And I’ve just gone a little sniff a little smell that perhaps what’s going on here is we don’t view patients experience with the same status as we do traditional research evidence. So that’s why I think it’s taken so long for any of this to be given attention. And it’s something just to watch, see how it plays out. Because we tend to hold, I think wrongly, too much faith in randomized control trials, and other ways of gaining evidence as it were, and hold that up as being the truth. And, and we write it off patients experiences just being anecdotal. And but the problem with that is when you have thousands of people saying something, you can’t call it anecdotal, you know that it’s no longer a coincidence, it becomes something that we should listen to and take seriously.

Adina Silvestri 20:11
Yeah, and so Ian, can you tell me a little bit about the concerns that these patients have?

Ian Hamilton 20:16
So there, as I say, they’re very they partly instigated this report, they were saying, you know, what you wouldn’t expect to hear or you might expect to hear the symptoms they were describing for something like heroin or oxycodone, don’t know, Tramadol, or whatever. But you wouldn’t normally associated with antidepressants. So what they were saying is, when their antidepressants are withdrawn or reduced, they start feeling really uncomfortable. And so you know, they might get very anxious, they might start getting problems with sleep, they can’t think as clearly, their appetite is gone. And they lose hope they lose enjoyment, etc, etc. So, you know, those, there’s a more than serious kind of symptoms, there’s a symptoms and experiences that can have a real impact on your life and those around you your ability to work, your ability to maintain relationships, and write down to, you know, everyday things like driving and operating machinery and doing your work, you know, so these are things that need to be taken seriously. And I think the report in fairness to it recognizes that we don’t yet have evidence of dependency, and even the evidence around withdrawal, in terms of research evidence is fairly weak. But that doesn’t mean to say it doesn’t exist.

Adina Silvestri 21:46
Yeah.

That’s so interesting. So if the patients are the ones that instigated this report, what does that mean for, for us for the for the clinicians? And, you know, how do we make sure that their voices get heard? And there might not be an answer to that

Ian Hamilton 22:06
I think that’s a really good point. You know, it’s one thing to be talking about all this and recognize it. It’s another thing to think, Well, how do you apply this in practice? So I think what what position most physicians are good at is listening, and treating everyone as an individual hopefully. So I think it’s just important to listen to what people are saying and describing the behaviors, the feelings, and the symptoms that they experience. And, you know, we can learn from history over this way, you know, with benzodiazepines with diazepam, when that happened 20, 30 years ago, people were being reduced far too quickly. And from really high doses, to nothing in a matter of weeks. And no wonder people relapsed, and then went on to the black market to source drugs, because it just was too painful, too uncomfortable well, so I think we can learn something from that. And just let’s look at tapering doses, let’s look at providing other forms of support when people experience these symptoms to make it a bit more comfortable or less uncomfortable. And so I think there’s a whole load of things that physicians can do, or they can at least refer people on to other forms of support, you know, giving pills on their own, we knew as physicians is not the best thing to do, the evidence is behind pills plus talking, that that’s where the best evidence is. So if people haven’t had access to talk in therapy, I hope that we’d be able to recommend and facilitate it. And just taking our time listening, and being respectful of people’s experiences, even if it doesn’t match what we think should be happening, we need to trust what people are saying, believe them, and go at their pace, not the pace, we think the should be going out in terms of tapering a drug down, prescription down and go at the person’s pace. I mean, be ambitious for them. Sometimes you’re the only person around them who is ambitious, and has their best interests at heart. But that doesn’t I think mitigate being kind and being respectful and trusting patients as well. You know, too often, I think there’s a subplot here of anyone who’s got a problem with a drug is automatically a liar, and, you know, someone that you shouldn’t trust. And I think that runs through even though in 2019, that’s still the case, as far as certainly some members of the public and I’m afraid to say some physicians and nurses are concerned, there’s still that stigma attached to dependency.

Adina Silvestri 24:55
Yes, yes, I wholeheartedly agree with that. So I want to, I want to switch gears and talk a little bit about, about just clinical depression for a moment. And in your article, you say that for many patients, clinical depression and pain and more than a solitary, solitary, psychological, physical problem?

Ian Hamilton 25:25
Well, you know, the thing that we don’t recognize with mental health is it’s it’s, it’s connected to physical health, it doesn’t have the same kind of presentation and way of diagnosing a problem as colleagues in physical health, we don’t have X rays for this, we don’t have MRI eyes and all the rest of it, we don’t have the fancy gadgets that tell us what’s going on, really. So what we rely on is obviously, the patient’s account of what’s going on in their life and collateral source of information as well. But we knew that mood affect, and levels of anxiety are molded by more than just your biochemistry, they are influenced by whether you work or not, whether you have a relationship or not. And the way that you were brought up, and perhaps some, you know, the extreme any trauma that you experienced, or even just milestones that you perhaps didn’t achieve, or felt you should have achieved. So a lot of this has to do with the individuals scanning of their immediate horizon, where do they fit in with everybody else? and everything else? What’s their status, what’s their role? Are they fulfilled all this kind of so called softer aspects to being human, and even, you know, spirituality, which is where we started this conversation. So I think, given how complex all that is, and the limited time certainly in the UK, you know, the average appointment time is nine minutes in general practice, well, you know, the time used to to learn how you’re doing, That only leaves you eight minutes to try and get to the bottom of something. So I think all I’m pointing out is something that I would imagine or who most people would recognize is that depression isn’t just a genetic predisposition, you know, you’re not just, it’s not just the way you’re born, this isn’t your destiny to have a little mood. This is about the experiences you have in life, you know, obviously, things like grief, loss of a job being made redundant, divorce, all those life. And factors will affect your mood. And that doesn’t mean to say you need a pill to rectify them. And but sometimes a pill is the easiest thing for a patient to take and a physician to offer. And, and it offers that kind of almost all it’s not instant, there’s a perception that it is an instant solution to sometimes a very interacted complex set of issues. And and it’s certainly UK, I don’t know about the US, but you you going to find it easiest to access an antidepressant then cognitive behavioral therapy, or family therapy or psychotherapy, we just don’t have enough in the way of talking therapy.

Adina Silvestri 28:30
Right. Or if you’re in that marginalized population, you don’t, you may not be taken seriously, or you may not have the means or the list goes on and on regarding talk therapy.

Ian Hamilton 28:42
Yeah, I mean, I think there’s a degree of collusion going on here without wanting to sound dramatic between physician and patient. So if you’re a doctor working in a very deprived area, you know, what the problems are, there is lack of hope, for that individually in terms of employment of life opportunity. And so, and there’s also, as I say, a lack of infrastructure around health and infrastructure, so lack of access to talking therapy, etc. So what do you do you know, you are faced with someone who is depressed, the depression is likely has its roots in that person’s disadvantage. And why wouldn’t you offer something that you think might help, even though it’s not the best or optimum thing, and that thing is a pill, you know, and it’s, I think the physician knows this, the prescriber knows this, and to a greater or lesser degree, so does the patient, but it offers some relief. And then why wouldn’t you do it? But of course, that’s, that’s a very short term horizon and perspective to have I mean, you know, I see this as political as well, you know, we have to look at social inequality and all this and why is it some people have this disadvantage? And why is it intergenerational, it’s not just in the current generation, this is going back two or three generations through to parents and grandparents. And so, you know, I think politicians and policymakers have some responsibility in their role and part of their role is not the whole picture, but partly have a role in turning this around so that we make sure people have access to antidepressants when they need them. But we don’t over medicate the masses, social inequality and other aspects of life, which have nothing to do with mental health, as it were, but do obviously influence how someone feels and their lack of hope and aspiration.

Adina Silvestri 30:51
Yeah. Right.

That’s probably a good place to to wind down.

I have so many other questions.

That will save them for next time.

Ian Hamilton 31:08
Oh, that’d be great.

Adina Silvestri 31:12
Ian, if you had a time machine, and you could travel into the future, what would you see? What would recovery look like in the distant future?

Ian Hamilton 31:21
Well, I think it’s maybe not the distant future, I think we’re beginning to get there, we’re beginning to understand that recovery isn’t a one size fits all. It’s not not like going to, you know, buy clothes where you get small, medium, and large, you know, recovery is a very individual thing. And we’re beginning to recognize that so we are recognizing it in the treatments we’re offering in the length of time it takes for people to reach recovery, and what recovery looks like recovery is going to look very different from one person to another. So I think that’s great. And that really gives me hope it gives me up optimism for the future. You know, I’ve I’ve got the benefit of 30 years in this field. And that’s one of the really significant changes I’ve seen is rather than trying to apply a generic one size fits all, as I say, definition of recovery, we’re beginning to accept that that looks very different for each person. And I celebrate that that’s fantastic. Because it means that people don’t have to feel as though they have to fit one definition or one style of recovery, it can be very different. For two people in the same area. Thank you for that.

Adina Silvestri 32:37
What are some of the best ways to find you and all the awesome work that you do in the in the community and for for the medical community as well.

Ian Hamilton 32:47
That was very kind. Probably on Twitter. So my Twitter handle is, and I can never remember those little lines of course, but Ian little line, Hamilton little line, wherever those things are called underscore, I think Ian underscore Hamilton underscore so I’m, you know, I’m pretty active on Twitter. And, and I find it’s a great way of finding new things. I have exchanging ideas and just getting into some great conversations. So by all means, if you want to hook up that way, more than happy to do that.

Adina Silvestri 33:24
Great. Thank you so much for for coming on today. Really appreciate it.

Ian Hamilton 33:29
My absolute pleasure, Adina, thanks for having me on. Okay,

Cheers. Bye.

Adina Silvestri 33:36
Thank you for listening to the atheists in recovery podcast. For more great info and to stay up to date. Head over to atheistsinrecovery.com