I just had to write one more post regarding psychiatric medications.
Last night I was watching TV and saw a commercial for Abilify. This is a neuroleptic medication being used as a supplement for antidepressants by physicians in the treatment of depression. This combination has been used for several years now.
My objection is not to the use of the combination by a trained professional. My objection is to the direct marketing of the combination--the so called "drug cocktail"--to the American people. Do we really want to be sending this message out to America? The message is no longer simply that "You may need an antidepressant to help you out of your depression." The message is now, "You may need two (or even more) drugs to help you out of your depression." I put part of that sentence in parentheses because I believe that there is an implicit idea here. If two medications may be needed, then isn't there an underlying implication that three or four may be needed?
Let's imagine the TV commercials of the future.
"Have you been taking three or more psychiatric drugs and still feeling depressed? Has the combination of methylphenidate, Zoloft, and Provigil left you listless and unsatisfied? Scientists have now found that the addition of one more medication--Prohazard--helps many whose depression was not responding to only three drugs. With the addition of a fourth--Prohazard, you may be able to feel zest and happiness in your life again."
While the above commercial seems laughable, what is unbelievable today is the fact of tomorrow. What is outrageous today may be commonplace and taken for granted tomorrow. Where do we draw the line in the marketing of pharmaceuticals as a necessity of life? When do we wake up as a society and realize that we are giving exactly the wrong message to our citizens? While pharmacotherapy may be needed now and then, the main message that we need to be sending to the populace is that there are a variety of ways of coping with stress and that medication is only one of these. Psychological coping skills offer a way of being calmer and more self-reliant. For most people, medication is not the first option that needs to be considered.
Now readers of my blog know that I am not against pharmacotherapy for psychological problems. However, I am against the direct marketing of drug cocktails to our citizenry. The basic message is this, "You are so flawed and so helpless in the face of emotional distress that you need one or even several medications to make you right." This is a message which saps the very fiber of the American people. You need this. You need that. You are unable on your own to cope.
If a psychiatrist believes a patient is in need of more than one medication (and they often do), then I will leave that to their discretion. But what are we teaching ourselves and our children with these TV commercials?
Wednesday, November 30, 2011
Saturday, November 19, 2011
Some Final Notes Regarding the Book Anatomy of an Epidemic
Some final thoughts on the use of psychiatric medications.
--There is no doubt that many people need psychiatric medication. Their depression, psychosis, or anxiety is so severe that it disables them. And they need treatment--NOW. People have to get back to work. They have to pay the mortgage. Children may have misbehaved so badly due to ADHD that if they do not quickly change they will be expelled from school. Parents may need to quickly calm their explosiveness so as to not emotionally injure their children. Persons with a severe case of mental disorder may be so sabotaging their life that to wait for long term improvement with counseling or psychotherapy is not feasible, even if long term counseling or psychotherapy is the better treatment in the long run.
--But troubling issues remain. How do we know that psychiatric medications are safe and efficacious over the long run, when they are taken for years or decades? I do not believe that there is data to support this.
--I wonder if all of the relevant research on this issue has been published. Has any been withheld? It is generally known that journals will generally not print studies which show that no significant experimental effects have occurred. So if a long term study existed that did not show a beneficial effect of medication over placebo, would it be printed? One important study, the Harrow study*, apparently was turned down by American psychiatric journals. Was it because they considered it poor science? Or because the results went against the grain of accepted psychiatric beliefs?
--Long term effects are hard to research. It is hard to conduct a randomized study for more than a few months. People don't want to abide by a tightly controlled treatment regimen. People on medications during the acute phase of a study may, in the followup phase, want to start psychotherapy or may want to be on no treatment at all. People who have been treated with psychotherapy may want to start medication. And when people do change their treatment, it is not random. They may get off of medications because the medications have made them feel better or made them feel worse. All of this makes controlled comparisons over the long term very difficult indeed. (Hopefully, some very bright researchers will find a way around these problems.)
--If science is providing better and better treatments, then why are rates of mental illness going up rather than down? Why are rates of bipolar disorder going up? The increase in the use of antidepressants and mood stabilizers has been suggested as one possible explanation of increasing chronicity. But very long term trends are difficult to interpret. There are concurrent, ongoing social changes which confound easy analysis. There are changes in the public's use of street drugs, changes in the welfare system that reimburse people who are mentally ill, changed attitudes about reporting symptoms that make people more open about talking about their difficulties, changes in the diagnostic criteria, and changes in the social fabric and social support available to persons. The increasing stresses of modern society also cannot be overlooked as the possible culprit causing a long term trend causing elevations in some psychiatric diagnoses.
--Is there a conspiracy to get people to take drugs that they don't need? Hardly. Is there an economic system which rewards doctors and pharmaceutical companies for treating mental illness with psychotherapy? Absolutely. There is no way to get around the fact that a decreased use of psychiatric medications would severely impact the viability of both psychiatry and much of the pharmaceutical industry. It is a merry round which it would be difficult for them to get off.
--There is no doubt that there are clearly biological foundations for many mental disorders. The research is voluminous. I believe it is incontrovertible. Many mental disorders have biological correlates. Period. But that does not necessarily mean that in all cases, these disorders will respond best to a biologically oriented treatment. It is still theoretically possible that the body remains the best healer, or that psychotherapy is the best approach. (Psychotherapy can be conceptualized as clearing away obstacles which would inhibit the body from healing itself.)
--Some psychologists and mental health professionals would argue that psychological avoidance is the source of many if not most mental health problems--avoidance of internal thoughts and feelings, and avoidance of dealing with problems. Are we as a society encouraging avoidance by advocating the widespread use of medication? And in so doing, are we thus actually making psychological problems worse? Iatrogenesis is the causing of problems through medical treatment. Is that occurring here with an over reliance on psychiatric drugs? If there are natural healing forces in the brain, are the biological treatments we are using helping or hindering them?
--On the other hand, if everyone suddenly went off all psychiatric drugs, would there be enough counselors to deal with the number of patients?
--In the long run the scientific method will correct any current fallacies. Science tends to correct itself. However, in the short run, journal editorial decisions, and grant funding decisions at a federal level could impede some of data which is negative about pharmacotherapy from being collected or published. Science eventually corrects itself, but it sometimes takes a long time. As one author I once read put it, referring to Einstein and the quantum revolution in physics, old scientists don't change their minds, they just pass away. (I'm sorry I don't have the reference; it was in a biography of Einstein).
--People sometimes talk about drugs as being a crutch. They sometimes talk about psychotherapy in the same way. But I believe that misses the important point. Crutches are good things. Or at least I would think so if I broke my leg. But a crutch is a temporary thing. It allows healing by taking the stress off of the body. All medical treatments, whether they are pharmacotherapy or psychotherapy need to encourage the body in its own natural healing. And if they cannot encourage natural bodily (or brain) healing, they at least need to permit it to occur. (This may seem to contradict my point about the use of psychiatric medications being a way of avoiding dealing with problems. There is considerable complexity in this issue. I believe that in an ideal situation, the psychiatric drugs would be used for a short period of time alongside a psychotherapy plan of helping the person to psychologically deal with issues.)
--Psychiatric research is not necessarily objective. In one research program in which I participated, the results of a study indicated a slight advantage of the antidepressant condition over psychotherapy, at least in the short run (the acute phase of the study; in the followup phase, the cognitive therapy did better than the medication.) A nationally known psychiatrist was highly bothered that the benefit of the medication was not found to be stronger. He insisted that a new more powerful statistical technique be used to look for differences between the different treatments (essentially pharmacotherapy versus psychotherapy). Now, you need to understand that we already had TOP statisticians on the project. But with the use of the new statistic, the effect of the medication condition was a little stronger. This was an example of statistics being used in the service of ideology. It is not for me to say whether the statistic was valid or not. I assume that it was. However, if there had not been such ideological devotion to the medication condition being superior by this one influential psychiatrist, there would never have been such an impetus to look around for another statistic and to perform a reanalysis.
*M. Harrow, "Factors Involved in Outcome and Recovery in Schizophrenia Patients Not on Antipsychotic Medication." The Journal of Nervous and Mental Disease, 195 (2007): 406-414. The study seemed to show that psychotic individuals who went off of their medications did better than individuals who stayed on them. The data is open to various interpretations; but it is surprising that it did not receive more prominent journal coverage. In general, it is surprising that it has not been talked about more widely.
--There is no doubt that many people need psychiatric medication. Their depression, psychosis, or anxiety is so severe that it disables them. And they need treatment--NOW. People have to get back to work. They have to pay the mortgage. Children may have misbehaved so badly due to ADHD that if they do not quickly change they will be expelled from school. Parents may need to quickly calm their explosiveness so as to not emotionally injure their children. Persons with a severe case of mental disorder may be so sabotaging their life that to wait for long term improvement with counseling or psychotherapy is not feasible, even if long term counseling or psychotherapy is the better treatment in the long run.
--But troubling issues remain. How do we know that psychiatric medications are safe and efficacious over the long run, when they are taken for years or decades? I do not believe that there is data to support this.
--I wonder if all of the relevant research on this issue has been published. Has any been withheld? It is generally known that journals will generally not print studies which show that no significant experimental effects have occurred. So if a long term study existed that did not show a beneficial effect of medication over placebo, would it be printed? One important study, the Harrow study*, apparently was turned down by American psychiatric journals. Was it because they considered it poor science? Or because the results went against the grain of accepted psychiatric beliefs?
--Long term effects are hard to research. It is hard to conduct a randomized study for more than a few months. People don't want to abide by a tightly controlled treatment regimen. People on medications during the acute phase of a study may, in the followup phase, want to start psychotherapy or may want to be on no treatment at all. People who have been treated with psychotherapy may want to start medication. And when people do change their treatment, it is not random. They may get off of medications because the medications have made them feel better or made them feel worse. All of this makes controlled comparisons over the long term very difficult indeed. (Hopefully, some very bright researchers will find a way around these problems.)
--If science is providing better and better treatments, then why are rates of mental illness going up rather than down? Why are rates of bipolar disorder going up? The increase in the use of antidepressants and mood stabilizers has been suggested as one possible explanation of increasing chronicity. But very long term trends are difficult to interpret. There are concurrent, ongoing social changes which confound easy analysis. There are changes in the public's use of street drugs, changes in the welfare system that reimburse people who are mentally ill, changed attitudes about reporting symptoms that make people more open about talking about their difficulties, changes in the diagnostic criteria, and changes in the social fabric and social support available to persons. The increasing stresses of modern society also cannot be overlooked as the possible culprit causing a long term trend causing elevations in some psychiatric diagnoses.
--Is there a conspiracy to get people to take drugs that they don't need? Hardly. Is there an economic system which rewards doctors and pharmaceutical companies for treating mental illness with psychotherapy? Absolutely. There is no way to get around the fact that a decreased use of psychiatric medications would severely impact the viability of both psychiatry and much of the pharmaceutical industry. It is a merry round which it would be difficult for them to get off.
--There is no doubt that there are clearly biological foundations for many mental disorders. The research is voluminous. I believe it is incontrovertible. Many mental disorders have biological correlates. Period. But that does not necessarily mean that in all cases, these disorders will respond best to a biologically oriented treatment. It is still theoretically possible that the body remains the best healer, or that psychotherapy is the best approach. (Psychotherapy can be conceptualized as clearing away obstacles which would inhibit the body from healing itself.)
--Some psychologists and mental health professionals would argue that psychological avoidance is the source of many if not most mental health problems--avoidance of internal thoughts and feelings, and avoidance of dealing with problems. Are we as a society encouraging avoidance by advocating the widespread use of medication? And in so doing, are we thus actually making psychological problems worse? Iatrogenesis is the causing of problems through medical treatment. Is that occurring here with an over reliance on psychiatric drugs? If there are natural healing forces in the brain, are the biological treatments we are using helping or hindering them?
--On the other hand, if everyone suddenly went off all psychiatric drugs, would there be enough counselors to deal with the number of patients?
--In the long run the scientific method will correct any current fallacies. Science tends to correct itself. However, in the short run, journal editorial decisions, and grant funding decisions at a federal level could impede some of data which is negative about pharmacotherapy from being collected or published. Science eventually corrects itself, but it sometimes takes a long time. As one author I once read put it, referring to Einstein and the quantum revolution in physics, old scientists don't change their minds, they just pass away. (I'm sorry I don't have the reference; it was in a biography of Einstein).
--People sometimes talk about drugs as being a crutch. They sometimes talk about psychotherapy in the same way. But I believe that misses the important point. Crutches are good things. Or at least I would think so if I broke my leg. But a crutch is a temporary thing. It allows healing by taking the stress off of the body. All medical treatments, whether they are pharmacotherapy or psychotherapy need to encourage the body in its own natural healing. And if they cannot encourage natural bodily (or brain) healing, they at least need to permit it to occur. (This may seem to contradict my point about the use of psychiatric medications being a way of avoiding dealing with problems. There is considerable complexity in this issue. I believe that in an ideal situation, the psychiatric drugs would be used for a short period of time alongside a psychotherapy plan of helping the person to psychologically deal with issues.)
--Psychiatric research is not necessarily objective. In one research program in which I participated, the results of a study indicated a slight advantage of the antidepressant condition over psychotherapy, at least in the short run (the acute phase of the study; in the followup phase, the cognitive therapy did better than the medication.) A nationally known psychiatrist was highly bothered that the benefit of the medication was not found to be stronger. He insisted that a new more powerful statistical technique be used to look for differences between the different treatments (essentially pharmacotherapy versus psychotherapy). Now, you need to understand that we already had TOP statisticians on the project. But with the use of the new statistic, the effect of the medication condition was a little stronger. This was an example of statistics being used in the service of ideology. It is not for me to say whether the statistic was valid or not. I assume that it was. However, if there had not been such ideological devotion to the medication condition being superior by this one influential psychiatrist, there would never have been such an impetus to look around for another statistic and to perform a reanalysis.
*M. Harrow, "Factors Involved in Outcome and Recovery in Schizophrenia Patients Not on Antipsychotic Medication." The Journal of Nervous and Mental Disease, 195 (2007): 406-414. The study seemed to show that psychotic individuals who went off of their medications did better than individuals who stayed on them. The data is open to various interpretations; but it is surprising that it did not receive more prominent journal coverage. In general, it is surprising that it has not been talked about more widely.
Wednesday, November 16, 2011
If Not Medications, Then What--Natural Healing?
This is a second followup to my post, Anatomy of an Epidemic.
I was somewhat reluctant to use the phrase "natural healing" in this title, but I decided upon it anyway. Why was I reluctant? Because over the years, "natural healing" has generally meant people avoiding scientifically proven treatments in favor of something like changing their diet. Steve Jobs postponed surgery and chemotherapy for his pancreatic cancer in favor of natural healing methods. I had a patient in psychotherapy who did the same thing when he was diagnosed with cancer. Eventually, he chose to go with more traditional scientific treatments, but it was too late. The "natural healing" route led to his death.
So why am I now writing about natural healing? Well, if you have read my posting on Anatomy of an Epidemic, you will see that there appear to be some problems with psychiatric drugs. They may work well in the short run but pose problems in the long run.
Secondly, while I love my profession of psychology and while I posted a column on psychotherapy as an alternative treatment to medication, I am well aware that the world got along fairly well without psychologists, social workers, psychiatrists, and counselors for a long, long time. It is the height of pride to pretend that people cannot heal from psychological problems without the help of psychologists or other mental health professionals. There were healing mechanisms in the human race before there was ever a Carl Rogers, B.F. Skinner, or Aaron Beck. Moreover, not everyone can afford psychotherapy. Furthermore, if everyone that needed it started utilizing psychotherapy, there might not be enough trained therapists to go around. I'm fairly sure that there would not be.
So I want to write some about natural healing mechanisms. How powerful are they? I'm not sure. In some cases I think they are more power than all of the professional means of treatment. In other situations, they are probably less powerful.
Let's divide the natural healing mechanisms into two sorts. One sort is what happens in everyday life to build us up and make us better and stronger mentally, whether or not we are sick, and whether or not we are depressed.
The second type of healing mechanism is the kind which occurs in response to psychological illness. We'll start with general psychological strengthening factors which serve to help prevent mental illness.
Good diet nutrition. Okay, this is the one I am not crazy about. The brain can actually get by on junk food to a great degree without any mental illness occurring. On the other hand, there are some studies about the importance of nutrition in mental health. Here is a quote from an article by Serdar M. Durson, MD. PhD, Professor of Psychiatry and Neuroscience at the University of Alberta:
"Vitamin D and receptors have been increasingly implicated in the pathology of cognition and mental illness. Vitamin D activates receptors on neurons in regions implicated in the regulation of behaviour, stimulates neurotrophin release and protects the brain by buffering antioxidant and anti-inflammatory defences against vascular injury. There is growing evidence for a relationship between vitamin D receptors in the brain, hypovitaminosis D and abnormal executive cognitive functions, major depression, bipolar disorder, and schizophrenia." I use this one quote because of its directness and clarity. There may be many other examples of where nutrition impacts mental health/
Fun and recreation. Recreation is used as a therapeutic modality in the elderly and hospitalized patients, but here I am referring to the normal building up of the mind and body through having fun and activity.
Exercise. Exercise is also being used as a therapeutic method. Exercise has been shown to have strong antidepressant effects. But generally people use exercise for its preventative qualities. Exercise improves blood flow to the brain and probably promotes neurogenesis (growth of new nerve cells).
Spiritual life, prayer, meditation, contemplative reading. While this can be thought of as a type of therapy, spirituality is at its heart a normal part of everyday life for some people. It helps people have a sense of meaning and purpose in life. It promotes a feeling of calmness in the face of adversity.
Staying off of drugs (including nicotine), excessive prescription medication. A healthy lifestyle is undoubtedly going to lead to better mental health. Studies are beginning to suggest, for example, that using illegal drugs can sometimes lead to psychotic breaks.
Natural problem solving processes. People normally have to solve problems. Learning how to solve problems and then using these abilities to deal with life issues removes sources of stress in life.
The distraction of work and life in general. Going to work can be a great distraction from certain types of stresses. Without work and recreation, we can easily get trapped into a cycle of worry, rumination, and dwelling on the negative.
The enforced use of the frontal lobes of the brain. Having to go to work and having to solve problems in life is most likely stimulating to the frontal lobes of the brain. When we use a part of the brain, then we are most likely increasing the regional cerebral blood flow to it and most likely improving its overall physiological functioning. I believe that using the frontal lobes in a positive way is good preventive medicine.
Jerome Frank wrote a book decades ago called Persuasion and Healing. He looked at psychotherapy as being a form of healing which had previously taken place in shamanic rituals and even in frontier revivalism. Society has rituals of many sorts: church, football games, presidential inaugurations, and so on. I believe that participating in rituals of the larger society gives us feelings of belonging, meaning, and security.
I believe that another form of normal positive mental health is the learning of virtues. We may be taught these by our parents; or we may be inspired by those among us who are exceptional persons and particularly positive in their outlook. In religion, we call these people saints. In secular life, we call them leaders or creative geniuses. Marten Seligman and Christopher Peterson have recently combed through the world's literature, cultures, and religions to catalog positive virtues.
One non-medical form of healing comes in the form of practical help when people have started to become dysfunctional. Often when someone is depressed, others come to their aid in practical ways, bringing food, helping them repair something, and so on. The importance of practical assistance is twofold. It helps eliminate a tangible stress (such as repairing a house which has been flooded), and it shows caring. When people come to visit us to show that they care, they communicate this by their presence, their words, and their nonverbal gestures. I believe that this probably elicits a positive response in the brain of the recipient which is hardwired. That is, I believe that the brain is genetically prepared to have a beneficial response to these types of caring gestures.
Corrective brain processes. The brain most likely has its own physiological healing processes. Just as the rest of the body can heal from an injury, so, too, the brain probably has its own healing powers.
Distance from the stressor in time. Time itself can probably heal. As we move farther away from a stress, most stresses seem smaller and smaller to us. This can be thought of as a healing mechanism.
Distance from the stressor in space. If we move away from a stressor, it can be less of a problem for us. We can start to forget it. An example would be moving away from an area where an ex-spouse who was abusive lives.
Increased family cohesiveness. When patients are hospitalized, it is often the case that family members will come to express concern for them. Family members will often tone down conflict in order to be supportive of the hospitalized patient.
Social rituals may be helpful in general, but they may also be used in response to stressful life events. One example would be people going to a revival for faith healing or being prayed for in a prayer group.
Social help normalizing and metabolizing the stressor. When we have a problem, it can at first seem outrageous, unbelievable, impossible, and even scandalous. It is outside of our realm of experience or outside of our range of known coping abilities. When we talk about our problems with others, they can intellectually and emotionally help us to digest them. They listen to our problems, empathize with us, and then think through the problem solving process with us. This has been conceptualized as helping the distressed person to "metabolize" the problem.
In conclusion, I think we need to remember that medication and psychotherapy are new treatments of the last one hundred years or so. There are other healing processes which have been available to humans and which are available to us. In some cases, these may be more powerful than medical and psychological treatments.
I was somewhat reluctant to use the phrase "natural healing" in this title, but I decided upon it anyway. Why was I reluctant? Because over the years, "natural healing" has generally meant people avoiding scientifically proven treatments in favor of something like changing their diet. Steve Jobs postponed surgery and chemotherapy for his pancreatic cancer in favor of natural healing methods. I had a patient in psychotherapy who did the same thing when he was diagnosed with cancer. Eventually, he chose to go with more traditional scientific treatments, but it was too late. The "natural healing" route led to his death.
So why am I now writing about natural healing? Well, if you have read my posting on Anatomy of an Epidemic, you will see that there appear to be some problems with psychiatric drugs. They may work well in the short run but pose problems in the long run.
Secondly, while I love my profession of psychology and while I posted a column on psychotherapy as an alternative treatment to medication, I am well aware that the world got along fairly well without psychologists, social workers, psychiatrists, and counselors for a long, long time. It is the height of pride to pretend that people cannot heal from psychological problems without the help of psychologists or other mental health professionals. There were healing mechanisms in the human race before there was ever a Carl Rogers, B.F. Skinner, or Aaron Beck. Moreover, not everyone can afford psychotherapy. Furthermore, if everyone that needed it started utilizing psychotherapy, there might not be enough trained therapists to go around. I'm fairly sure that there would not be.
So I want to write some about natural healing mechanisms. How powerful are they? I'm not sure. In some cases I think they are more power than all of the professional means of treatment. In other situations, they are probably less powerful.
Let's divide the natural healing mechanisms into two sorts. One sort is what happens in everyday life to build us up and make us better and stronger mentally, whether or not we are sick, and whether or not we are depressed.
The second type of healing mechanism is the kind which occurs in response to psychological illness. We'll start with general psychological strengthening factors which serve to help prevent mental illness.
Natural Healing Factors
Good diet nutrition. Okay, this is the one I am not crazy about. The brain can actually get by on junk food to a great degree without any mental illness occurring. On the other hand, there are some studies about the importance of nutrition in mental health. Here is a quote from an article by Serdar M. Durson, MD. PhD, Professor of Psychiatry and Neuroscience at the University of Alberta:
"Vitamin D and receptors have been increasingly implicated in the pathology of cognition and mental illness. Vitamin D activates receptors on neurons in regions implicated in the regulation of behaviour, stimulates neurotrophin release and protects the brain by buffering antioxidant and anti-inflammatory defences against vascular injury. There is growing evidence for a relationship between vitamin D receptors in the brain, hypovitaminosis D and abnormal executive cognitive functions, major depression, bipolar disorder, and schizophrenia." I use this one quote because of its directness and clarity. There may be many other examples of where nutrition impacts mental health/
Fun and recreation. Recreation is used as a therapeutic modality in the elderly and hospitalized patients, but here I am referring to the normal building up of the mind and body through having fun and activity.
Exercise. Exercise is also being used as a therapeutic method. Exercise has been shown to have strong antidepressant effects. But generally people use exercise for its preventative qualities. Exercise improves blood flow to the brain and probably promotes neurogenesis (growth of new nerve cells).
Spiritual life, prayer, meditation, contemplative reading. While this can be thought of as a type of therapy, spirituality is at its heart a normal part of everyday life for some people. It helps people have a sense of meaning and purpose in life. It promotes a feeling of calmness in the face of adversity.
Staying off of drugs (including nicotine), excessive prescription medication. A healthy lifestyle is undoubtedly going to lead to better mental health. Studies are beginning to suggest, for example, that using illegal drugs can sometimes lead to psychotic breaks.
Natural problem solving processes. People normally have to solve problems. Learning how to solve problems and then using these abilities to deal with life issues removes sources of stress in life.
The distraction of work and life in general. Going to work can be a great distraction from certain types of stresses. Without work and recreation, we can easily get trapped into a cycle of worry, rumination, and dwelling on the negative.
The enforced use of the frontal lobes of the brain. Having to go to work and having to solve problems in life is most likely stimulating to the frontal lobes of the brain. When we use a part of the brain, then we are most likely increasing the regional cerebral blood flow to it and most likely improving its overall physiological functioning. I believe that using the frontal lobes in a positive way is good preventive medicine.
Jerome Frank wrote a book decades ago called Persuasion and Healing. He looked at psychotherapy as being a form of healing which had previously taken place in shamanic rituals and even in frontier revivalism. Society has rituals of many sorts: church, football games, presidential inaugurations, and so on. I believe that participating in rituals of the larger society gives us feelings of belonging, meaning, and security.
I believe that another form of normal positive mental health is the learning of virtues. We may be taught these by our parents; or we may be inspired by those among us who are exceptional persons and particularly positive in their outlook. In religion, we call these people saints. In secular life, we call them leaders or creative geniuses. Marten Seligman and Christopher Peterson have recently combed through the world's literature, cultures, and religions to catalog positive virtues.
Natural Healing Factors in Response to Mental Illness
One non-medical form of healing comes in the form of practical help when people have started to become dysfunctional. Often when someone is depressed, others come to their aid in practical ways, bringing food, helping them repair something, and so on. The importance of practical assistance is twofold. It helps eliminate a tangible stress (such as repairing a house which has been flooded), and it shows caring. When people come to visit us to show that they care, they communicate this by their presence, their words, and their nonverbal gestures. I believe that this probably elicits a positive response in the brain of the recipient which is hardwired. That is, I believe that the brain is genetically prepared to have a beneficial response to these types of caring gestures.
Corrective brain processes. The brain most likely has its own physiological healing processes. Just as the rest of the body can heal from an injury, so, too, the brain probably has its own healing powers.
Distance from the stressor in time. Time itself can probably heal. As we move farther away from a stress, most stresses seem smaller and smaller to us. This can be thought of as a healing mechanism.
Distance from the stressor in space. If we move away from a stressor, it can be less of a problem for us. We can start to forget it. An example would be moving away from an area where an ex-spouse who was abusive lives.
Increased family cohesiveness. When patients are hospitalized, it is often the case that family members will come to express concern for them. Family members will often tone down conflict in order to be supportive of the hospitalized patient.
Social rituals may be helpful in general, but they may also be used in response to stressful life events. One example would be people going to a revival for faith healing or being prayed for in a prayer group.
Social help normalizing and metabolizing the stressor. When we have a problem, it can at first seem outrageous, unbelievable, impossible, and even scandalous. It is outside of our realm of experience or outside of our range of known coping abilities. When we talk about our problems with others, they can intellectually and emotionally help us to digest them. They listen to our problems, empathize with us, and then think through the problem solving process with us. This has been conceptualized as helping the distressed person to "metabolize" the problem.
In conclusion, I think we need to remember that medication and psychotherapy are new treatments of the last one hundred years or so. There are other healing processes which have been available to humans and which are available to us. In some cases, these may be more powerful than medical and psychological treatments.
Sunday, November 13, 2011
If Not Medications, Then What? Psychotherapy.
In my last blog post, I wrote about the book Anatomy of an Epidemic and the possible dangers posed by long term use of some psychiatric drugs.
So what are the alternatives? Well, the logical alternative to psychiatric medication is psychotherapy. As a psychologist, I actually view psychotherapy as not just an alternative, but actually the first line of treatment for most psychological disorders. However, I am a realist, and I know that in this technological age filled with advertisements of every kind for psychiatric drugs. Many people may not longer see psychotherapy as the first line of treatment as I do.
The research literature is too voluminous to try and analyze it here, just as actually analyzing the effects of psychiatric drugs cannot be done in a small blog post. If you are really interested in the research literature on the efficacy of psychotherapy, try the National Library of Medicine web site, http://www.pubmed.com/. Then type in "efficacy of psychotherapy" or "metaanalysis of psychotherapy outcome". If you want even more information, try Michael Lambert's latest edition of the book titled Bergin and Garfield's Handbook of Psychotherapy and Behavior Change (only $185.20 in hardcover!).
Numerous types of psychotherapy are available. Psychotherapies used to be classified in the following ways: cognitive, behavioral, psychodynamic, client centered, eclectic, group therapy, family therapy, and so on. However, these days classifications of therapy tend to focus on diagnostic categories and which of the types of therapies listed above have been found to be efficacious. These are referred to as empirically verified therapies.
Here is a list of therapies proven to be efficacious in research research studies. This list was created through the American Psychological Association and was copied from the American Psychological Association web site.
Well-Established Treatments Citation for Efficacy Evidence
ANXIETY AND STRESS:
Cognitive behavior therapy for panic disorder with and without agoraphobia ...... Barlow et al. (1989); Clark et al. (1994)
Cognitive behavior therapy for generalized anxiety disorder............................ Butler et al. (1991); Borkovec et al. (1987)
Group cognitive behavioral therapy for social phobia..................................... Heimberg et al. (1990); Mattick & Peters (1988)
*Exposure treatment for agoraphobia.......................................................... Trull et al. (1988)
*Exposure treatment for social phobia......................................................... Feske et al; Chambless (1995)
Exposure and response prevention for obsessive-compulsive disorder............. Balkom et al. (1994)
*Stress Inoculation Training for Coping with Stressors................................... Saunders et al. (in press)
Systematic desensitization for simple phobia ............................................. Kazdin et al; Wilcoxon (1976)
DEPRESSION:
Cognitive therapy for depression ...............................................................Dobson (1989); DiMascio et al. (1979)
Interpersonal therapy for depression.........................................................................................Elkin et al. (1989)
HEALTH PROBLEMS:
*Behavior therapy for headache................................................................. Blanchard et al. (1987); Holroyd & Penzien (1990)
*Cognitive behavior therapy for irritable bowel syndrome................................ Blanchard et al. (1980); Lynch & Zamble (1989)
*Cognitive behavior therapy for chronic pain .............................................. Keefe et al. (1992); Turner & Clancy (1988)
*Cognitive-behavior therapy for bulimia........................................................ Agras et al. (1989); Thackwray et al. (1993)
Interpersonal therapy for bulimia ................................................................ Fairburn et al. (1993); Wilfley et al. (1993)
PROBLEMS OF CHILDHOOD:
*Behavior modification for enuresis............................................................. Houts et al. (1994)
Parent training programs for children with oppositional behavior ...................... Walter et al; Gilmore (1973); Wells & Egan (1988)
MARITAL DISCORD:
Behavioral marital therapy......................................................................... Azrin, Bersalel et al. (1980); Jacobson & Follette (1985)
SEXUAL DYSFUNCTION:
Behavior therapy for female orgasmic dysfunction and male erectile dysfunction LoPiccolo & Stock (1986); Auerbach & Kilmann (1977)
OTHER:
Family education programs for schizophrenia ............................................... Hogarty et al. (1986); Falloon et al. (1985)
Behavior modification for developmentally disabled individuals ....................... Scotti et al. (1991)
Token economy programs ......................................................................... Kazdin (1977); Liberman (1972)
Probably Efficacious Treatments Citation for Efficacy Evidence
ANXIETY:
Applied relaxation for panic disorder ........................................................... Öst (1988)
*Applied relaxation for generalized anxiety disorder....................................... Barlow et al., (1992); Borkovec & Costello, (1993)
*Exposure treatment for PTSD................................................................... Foa et al. (1991); Keane et al. (1989)
*Exposure treatment for simple phobia........................................................ Leitenberg et al; Callahan (1973); Öst et al. (1991)
*Stress Inoculation Training for PTSD ......................................................... Foa et al. (1991)
*Group exposure and response prevention for obsessive-compulsive disorder .. Fals-Stewart et al. (1993)
*Relapse prevention program for obsessive-compulsive disorder..................... Hiss et al. (1994)
CHEMICAL ABUSE AND DEPENDENCE:
*Behavior therapy for cocaine abuse .......................................................... Higgins et al. (1993)
*Brief dynamic therapy for opiate dependence.............................................. Woody et al. (1990)
*Cognitive therapy for opiate dependence.................................................... Woody et al. (1990)
*Cognitive-behavior therapy for benzodiazepine withdrawal
in panic disorder patients ...................................................................... Otto et al. (1994); Spiegel et al. (1993)
DEPRESSION:
*Brief dynamic therapy ............................................................................. Gallagher-Thompson & Steffen(1994)
*Cognitive therapy for geriatric patients....................................................... Scogin et al; McElreath (1994)
*Psychoeducational treatment ................................................................... Lewinsohn et al. (1989)
*Reminiscence therapy for geriatric patients .............................................. Arean et al. (1993); Scogin & McElreath (1994)
*Self-control therapy ................................................................................ Fuchs & Rehm (1977); Rehm et al. (1979)
HEALTH PROBLEMS:
*Behavior therapy for childhood obesity ...................................................... Epstein et al. (1994); Wheeler & Hess (1976)
*Group cognitive-behavior therapy for bulimia .............................................. Mitchell et al. (1990)
MARITAL DISCORD:
Emotionally focused couples therapy ......................................................... Johnson et al; Greenberg (1985)
Insight-oriented marital therapy.................................................................. Snyder et al. (1989, 1991)
PROBLEMS OF CHILDHOOD:
*Behavior modification of encopresis .......................................................... O'Brien et al. (1986)
*Family anxiety management training for anxiety disorders............................. Barrett et al. (in press)
OTHER:
Behavior modification for sex offenders....................................................... Marshall et al. (1991)
Dialectical behavior therapy for borderline personality disorder........................ Linehan et al. (1991)
Habit reversal and control techniques ......................................................... Azrin, Nunn et al; Frantz (1980)
Azrin, Nunn & Frantz-Renshaw (1980
It is an encouraging list. It is somewhat outdated now, but it shows just how far psychotherapy conceptualization and research has come.
It is important not to let the TV commercials subtly influence you into thinking that medication for psychological problems is all that exists. The problem is not that other treatments do not exist; the problem is that they have not been adequately publicized to the public.
So what are the alternatives? Well, the logical alternative to psychiatric medication is psychotherapy. As a psychologist, I actually view psychotherapy as not just an alternative, but actually the first line of treatment for most psychological disorders. However, I am a realist, and I know that in this technological age filled with advertisements of every kind for psychiatric drugs. Many people may not longer see psychotherapy as the first line of treatment as I do.
The research literature is too voluminous to try and analyze it here, just as actually analyzing the effects of psychiatric drugs cannot be done in a small blog post. If you are really interested in the research literature on the efficacy of psychotherapy, try the National Library of Medicine web site, http://www.pubmed.com/. Then type in "efficacy of psychotherapy" or "metaanalysis of psychotherapy outcome". If you want even more information, try Michael Lambert's latest edition of the book titled Bergin and Garfield's Handbook of Psychotherapy and Behavior Change (only $185.20 in hardcover!).
Numerous types of psychotherapy are available. Psychotherapies used to be classified in the following ways: cognitive, behavioral, psychodynamic, client centered, eclectic, group therapy, family therapy, and so on. However, these days classifications of therapy tend to focus on diagnostic categories and which of the types of therapies listed above have been found to be efficacious. These are referred to as empirically verified therapies.
Here is a list of therapies proven to be efficacious in research research studies. This list was created through the American Psychological Association and was copied from the American Psychological Association web site.
Examples of Empirically Validated Treatments
Well-Established Treatments Citation for Efficacy Evidence
ANXIETY AND STRESS:
Cognitive behavior therapy for panic disorder with and without agoraphobia ...... Barlow et al. (1989); Clark et al. (1994)
Cognitive behavior therapy for generalized anxiety disorder............................ Butler et al. (1991); Borkovec et al. (1987)
Group cognitive behavioral therapy for social phobia..................................... Heimberg et al. (1990); Mattick & Peters (1988)
*Exposure treatment for agoraphobia.......................................................... Trull et al. (1988)
*Exposure treatment for social phobia......................................................... Feske et al; Chambless (1995)
Exposure and response prevention for obsessive-compulsive disorder............. Balkom et al. (1994)
*Stress Inoculation Training for Coping with Stressors................................... Saunders et al. (in press)
Systematic desensitization for simple phobia ............................................. Kazdin et al; Wilcoxon (1976)
DEPRESSION:
Cognitive therapy for depression ...............................................................Dobson (1989); DiMascio et al. (1979)
Interpersonal therapy for depression.........................................................................................Elkin et al. (1989)
HEALTH PROBLEMS:
*Behavior therapy for headache................................................................. Blanchard et al. (1987); Holroyd & Penzien (1990)
*Cognitive behavior therapy for irritable bowel syndrome................................ Blanchard et al. (1980); Lynch & Zamble (1989)
*Cognitive behavior therapy for chronic pain .............................................. Keefe et al. (1992); Turner & Clancy (1988)
*Cognitive-behavior therapy for bulimia........................................................ Agras et al. (1989); Thackwray et al. (1993)
Interpersonal therapy for bulimia ................................................................ Fairburn et al. (1993); Wilfley et al. (1993)
PROBLEMS OF CHILDHOOD:
*Behavior modification for enuresis............................................................. Houts et al. (1994)
Parent training programs for children with oppositional behavior ...................... Walter et al; Gilmore (1973); Wells & Egan (1988)
MARITAL DISCORD:
Behavioral marital therapy......................................................................... Azrin, Bersalel et al. (1980); Jacobson & Follette (1985)
SEXUAL DYSFUNCTION:
Behavior therapy for female orgasmic dysfunction and male erectile dysfunction LoPiccolo & Stock (1986); Auerbach & Kilmann (1977)
OTHER:
Family education programs for schizophrenia ............................................... Hogarty et al. (1986); Falloon et al. (1985)
Behavior modification for developmentally disabled individuals ....................... Scotti et al. (1991)
Token economy programs ......................................................................... Kazdin (1977); Liberman (1972)
Probably Efficacious Treatments Citation for Efficacy Evidence
ANXIETY:
Applied relaxation for panic disorder ........................................................... Öst (1988)
*Applied relaxation for generalized anxiety disorder....................................... Barlow et al., (1992); Borkovec & Costello, (1993)
*Exposure treatment for PTSD................................................................... Foa et al. (1991); Keane et al. (1989)
*Exposure treatment for simple phobia........................................................ Leitenberg et al; Callahan (1973); Öst et al. (1991)
*Stress Inoculation Training for PTSD ......................................................... Foa et al. (1991)
*Group exposure and response prevention for obsessive-compulsive disorder .. Fals-Stewart et al. (1993)
*Relapse prevention program for obsessive-compulsive disorder..................... Hiss et al. (1994)
CHEMICAL ABUSE AND DEPENDENCE:
*Behavior therapy for cocaine abuse .......................................................... Higgins et al. (1993)
*Brief dynamic therapy for opiate dependence.............................................. Woody et al. (1990)
*Cognitive therapy for opiate dependence.................................................... Woody et al. (1990)
*Cognitive-behavior therapy for benzodiazepine withdrawal
in panic disorder patients ...................................................................... Otto et al. (1994); Spiegel et al. (1993)
DEPRESSION:
*Brief dynamic therapy ............................................................................. Gallagher-Thompson & Steffen(1994)
*Cognitive therapy for geriatric patients....................................................... Scogin et al; McElreath (1994)
*Psychoeducational treatment ................................................................... Lewinsohn et al. (1989)
*Reminiscence therapy for geriatric patients .............................................. Arean et al. (1993); Scogin & McElreath (1994)
*Self-control therapy ................................................................................ Fuchs & Rehm (1977); Rehm et al. (1979)
HEALTH PROBLEMS:
*Behavior therapy for childhood obesity ...................................................... Epstein et al. (1994); Wheeler & Hess (1976)
*Group cognitive-behavior therapy for bulimia .............................................. Mitchell et al. (1990)
MARITAL DISCORD:
Emotionally focused couples therapy ......................................................... Johnson et al; Greenberg (1985)
Insight-oriented marital therapy.................................................................. Snyder et al. (1989, 1991)
PROBLEMS OF CHILDHOOD:
*Behavior modification of encopresis .......................................................... O'Brien et al. (1986)
*Family anxiety management training for anxiety disorders............................. Barrett et al. (in press)
OTHER:
Behavior modification for sex offenders....................................................... Marshall et al. (1991)
Dialectical behavior therapy for borderline personality disorder........................ Linehan et al. (1991)
Habit reversal and control techniques ......................................................... Azrin, Nunn et al; Frantz (1980)
Azrin, Nunn & Frantz-Renshaw (1980
It is an encouraging list. It is somewhat outdated now, but it shows just how far psychotherapy conceptualization and research has come.
It is important not to let the TV commercials subtly influence you into thinking that medication for psychological problems is all that exists. The problem is not that other treatments do not exist; the problem is that they have not been adequately publicized to the public.
Sunday, November 06, 2011
Anatomy of an Epidemic--the Explosion of Psychiatric Drug Use in America
I'm reading a new book, Anatomy of an Epidemic. And I find it both interesting and disturbing.
The book takes a look at the abuses of psychiatric drugs which has increasingly arisen in our culture.
Now, I am not generally one to bash such drugs. My own background is of a psychologist trained in medical settings, where psychiatric drugs were used routinely and responsibly to help people. I have also worked in clinical research trials where medication was being compared with psychotherapy, and I have seen the data showing that in the short run, medicines work about as well as psychotherapy, and sometimes better. The settings I have worked in have usually, but not always, involved collegial relationships between the MD and non-MD professionals, so that patients could receive the best of both types of treatment.
Another reason I have been comfortable with patients receiving medications is that I am aware of the empirical literature on their effectiveness. My graduate school training taught me methodological theory and how to analyze outcome studies, to know what was a good outcome research study and what was not. I generally have kept abreast of research on outcomes of both medication in general and psychotherapy.
But after years of being in private practice and away from more intensive contact with research findings, I feel that perhaps I have been caught napping. This book has been a rude awakening. The author has done his homework extremely well, and he is getting invitations from prestigious groups in the U.S. and abroad to come present his point of view. He has ferreted out numerous studies and facts to back his statements. Everything he says is based on either a research study or on the opinions of biologically oriented psychiatrists and psychologists.
What is it that he points out?
Barbara had been somewhat of a child prodigy in piano. She had been quite brilliant. But she also had a very dysfunctional family and almost surely had inherited the bipolar gene set. By the time I had started treating her she was 50 years old. She spoke slowly, deliberately, and emphatically, making her appear to be of borderline intelligence. There was a childlike, regressed manner to her speech. I did not test her IQ, but I believe that if I had, it would have probably been around 80. Why had this woman declined so precipitously? I asked senior colleagues, and they did not know. The thinking at the time was that she must have had some form of undiagnosed schizophrenia. It was known that schizophrenia had a long term course which could result in severe deterioration. But the problem was that there was absolutely no evidence that she had schizophrenia. Her symptoms were controlled with Lithium, a medication for bipolar disorder. I lost track of Barbara after I left OUHSC, and then later I heard that she had died. I believe that it was due to complications of her severe smoking habit. I am left wondering if her fall from brilliant child pianist to a fairly simple minded existence was due to her medication. I suppose I will never know, but it is certainly a possibility. No other explanation made any sesne then or now.
The issues raised in this book will put some patients into a dilemma. Their trusted mental health professionals say one thing, that the medications are safe and efficacious, and this book implies something else. Is the glass half empty or half full? It also puts me into somewhat of a dilemma since I work very closely with psychiatrists. I respect them, their knowledge, and their experience. I respect their caring for their patients.
But let's say that the premise of the book is true and that there are significant negative effects of psychiatric medications in the long run. Let's go further and say that the positive effects from psychiatric medications decline for many patients in the long run, after a year or so. The research literature is still relatively strong in showing that these medications work in the short run (although the negative outcome literature may have been unreported). Let's say that I am the treating psychiatrist for a man with severe depression and anxiety. He is functioning poorly on the job, and he may lose it if he does not do better. Doesn't he need to improve as quickly as possible to keep his job? Imagine how my patients would feel if I said to them the following: "Just hold on without the medications. Using psychotherapy you will eventually do just as well and even better than with medication; but in the short run, you are not likely to improve as rapidly."
The outcome picture is more complicated if a person is on medication and receiving psychotherapy at the same time. They would receive the best of both worlds. But there might also be some withdrawal effects coming off of the medication. I certainly encountered that with one college professor I treated. He was convinced that his Xanax was a major culprit in causing him further problems. I doubted it at the time, but now I believe that he knew himself and his body fairly well and that he was correct. In that situation, coming off of the Xanax meant that we had to extend the psychotherapy to help him through the process of getting off the medication.
Not everyone has a negative reaction to medications. Not everyone has difficulty coming off of them. There are obvious ethical problems here. A person may lose their job if not rapidly treated. A person may be in needless pain due to severe depression and anxiety. (It is probably not overly dramatic to refer to moderate and severe anxiety as a form of torture.) A person with severe depression or anxiety might commit suicide without the relief available from medication. Rapid treatment is often necessary to prevent a person from doing things which are irreversible--not just commiting suicide but also making mistakes on the job or severe mistakes in parenting. If a person loses their job, their marriage, or their children, then the long term job of the psychotherapist becomes all that more difficult.
Patients need to be made aware of the positive and the negative outcomes from medication. This is true of psychiatric and non-psychiatric drugs. For my own practice, I am left in somewhat of a dilemma. Here are the resolutions I have made to myself.
1. To do more research on the negative outcomes of psychiatric drugs.
2. To tighten up my criteria for when I do and when I do not recommend medication evaluation. (I do not perform psychological testing and then recommend medication. I come up with a diagnosis and then recommend a medication evaluation for some patients. There is a difference.) Similarly, I will be more conservative in making those diagnoses which most often lead to medication (ADHD, bipolar disorder, psychosis).
3. To emphasize to patients that the medications may not be a long term treatment. I will encourage them to talk with their treating MD about just how long they would be on the medication and when it might be feasible to start coming off of it.
I will be writing more in future columns about this. There is a great deal at stake here for all involved.
The book takes a look at the abuses of psychiatric drugs which has increasingly arisen in our culture.
Now, I am not generally one to bash such drugs. My own background is of a psychologist trained in medical settings, where psychiatric drugs were used routinely and responsibly to help people. I have also worked in clinical research trials where medication was being compared with psychotherapy, and I have seen the data showing that in the short run, medicines work about as well as psychotherapy, and sometimes better. The settings I have worked in have usually, but not always, involved collegial relationships between the MD and non-MD professionals, so that patients could receive the best of both types of treatment.
Another reason I have been comfortable with patients receiving medications is that I am aware of the empirical literature on their effectiveness. My graduate school training taught me methodological theory and how to analyze outcome studies, to know what was a good outcome research study and what was not. I generally have kept abreast of research on outcomes of both medication in general and psychotherapy.
But after years of being in private practice and away from more intensive contact with research findings, I feel that perhaps I have been caught napping. This book has been a rude awakening. The author has done his homework extremely well, and he is getting invitations from prestigious groups in the U.S. and abroad to come present his point of view. He has ferreted out numerous studies and facts to back his statements. Everything he says is based on either a research study or on the opinions of biologically oriented psychiatrists and psychologists.
What is it that he points out?
- When outcome studies have been published, the positive aspects of outcomes have been touted, and the negative aspects, such as side effects or negative effects after drug withdrawal, have been downplayed almost to the point of being hidden.
- Outcome studies have often focused on the 12 to 16 week initial treatment period. This has always seemed to me to be logical. Most psychiatric drug effects would become visible and obvious during that time period. But in the very long run, some medications, such as lithium and neuroleptics (antipsychotics), may be having negative outcomes on cognitive functioning. (See my blog on dementia and bipolar disorder; I did not mention there the possibility that medication itself might be the cause of cognitive decline.)
- The 12 to 16 week studies generally do not spend much time or space talking about drastic withdrawal effects from some medications. Some antidepressants and some anti-anxiety medications are very hard to stop taking once they have been started.
- Some medications stop working. The NIMH sponsored study of stimulant medication for ADHD found a clear "winner" in medication for the first acute study period, but no clear advantage to medication over the long run.
- Some studies which did not find efficacy for medication have never been reported. Studies with results inconsistent with the prevailing viewpoints of biological psychiatry may be relegated to less well read journals and refused for publication by the top of the line journals.
- Pharmaceutical companies have often used psychiatric researchers as consultants. This compromises their objectivity by paying them salaries.
Barbara had been somewhat of a child prodigy in piano. She had been quite brilliant. But she also had a very dysfunctional family and almost surely had inherited the bipolar gene set. By the time I had started treating her she was 50 years old. She spoke slowly, deliberately, and emphatically, making her appear to be of borderline intelligence. There was a childlike, regressed manner to her speech. I did not test her IQ, but I believe that if I had, it would have probably been around 80. Why had this woman declined so precipitously? I asked senior colleagues, and they did not know. The thinking at the time was that she must have had some form of undiagnosed schizophrenia. It was known that schizophrenia had a long term course which could result in severe deterioration. But the problem was that there was absolutely no evidence that she had schizophrenia. Her symptoms were controlled with Lithium, a medication for bipolar disorder. I lost track of Barbara after I left OUHSC, and then later I heard that she had died. I believe that it was due to complications of her severe smoking habit. I am left wondering if her fall from brilliant child pianist to a fairly simple minded existence was due to her medication. I suppose I will never know, but it is certainly a possibility. No other explanation made any sesne then or now.
The issues raised in this book will put some patients into a dilemma. Their trusted mental health professionals say one thing, that the medications are safe and efficacious, and this book implies something else. Is the glass half empty or half full? It also puts me into somewhat of a dilemma since I work very closely with psychiatrists. I respect them, their knowledge, and their experience. I respect their caring for their patients.
But let's say that the premise of the book is true and that there are significant negative effects of psychiatric medications in the long run. Let's go further and say that the positive effects from psychiatric medications decline for many patients in the long run, after a year or so. The research literature is still relatively strong in showing that these medications work in the short run (although the negative outcome literature may have been unreported). Let's say that I am the treating psychiatrist for a man with severe depression and anxiety. He is functioning poorly on the job, and he may lose it if he does not do better. Doesn't he need to improve as quickly as possible to keep his job? Imagine how my patients would feel if I said to them the following: "Just hold on without the medications. Using psychotherapy you will eventually do just as well and even better than with medication; but in the short run, you are not likely to improve as rapidly."
The outcome picture is more complicated if a person is on medication and receiving psychotherapy at the same time. They would receive the best of both worlds. But there might also be some withdrawal effects coming off of the medication. I certainly encountered that with one college professor I treated. He was convinced that his Xanax was a major culprit in causing him further problems. I doubted it at the time, but now I believe that he knew himself and his body fairly well and that he was correct. In that situation, coming off of the Xanax meant that we had to extend the psychotherapy to help him through the process of getting off the medication.
Not everyone has a negative reaction to medications. Not everyone has difficulty coming off of them. There are obvious ethical problems here. A person may lose their job if not rapidly treated. A person may be in needless pain due to severe depression and anxiety. (It is probably not overly dramatic to refer to moderate and severe anxiety as a form of torture.) A person with severe depression or anxiety might commit suicide without the relief available from medication. Rapid treatment is often necessary to prevent a person from doing things which are irreversible--not just commiting suicide but also making mistakes on the job or severe mistakes in parenting. If a person loses their job, their marriage, or their children, then the long term job of the psychotherapist becomes all that more difficult.
Patients need to be made aware of the positive and the negative outcomes from medication. This is true of psychiatric and non-psychiatric drugs. For my own practice, I am left in somewhat of a dilemma. Here are the resolutions I have made to myself.
1. To do more research on the negative outcomes of psychiatric drugs.
2. To tighten up my criteria for when I do and when I do not recommend medication evaluation. (I do not perform psychological testing and then recommend medication. I come up with a diagnosis and then recommend a medication evaluation for some patients. There is a difference.) Similarly, I will be more conservative in making those diagnoses which most often lead to medication (ADHD, bipolar disorder, psychosis).
3. To emphasize to patients that the medications may not be a long term treatment. I will encourage them to talk with their treating MD about just how long they would be on the medication and when it might be feasible to start coming off of it.
I will be writing more in future columns about this. There is a great deal at stake here for all involved.
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