Abby, a fictional patient with severe depression, was referred to a psychiatrist after several unsuccessful medication trials. She was confident she understood her diagnosis but because medications hadn't helped or were intolerable she felt hopeless. When reviewing her previous treatments, Abby admitted, "I probably didn't give anything a chance to work. Everyone tells me I can get better without drugs. I know I need help but I'm too embarrassed to take anything". She had also experienced some unpleasant side effects that made it even more difficult to stick with treatment.
While psychologists and some psychiatrists provide talk therapy (psychotherapy) for the treatment of emotional distress and mental illness, only psychiatrists can prescribe. Ideally, psychiatrists should possess the knowledge and expertise necessary to treat serious mental illnesses with medication. These are essential tools of our trade, yet prescribing is not always well taught or well executed, which can cause harm to patients and to society.
Media reports highlighting snippets of negative medication research, without considering the larger body of data or clinical experience demonstrating the benefits of these treatments, cause tremendous harm. Fear of medication is endemic, especially for drugs considered to be "brain altering". The ubiquitous headline, "Psychiatric drugs are no more effective than placebo", is utterly false for most patients, but sadly, this belief has permeated our society.
Consequently, psychiatric medications are commonly regarded as dangerous, unnecessary, intolerable or ineffective. Antidrug and antipsychiatry zealots, egged on by irresponsible media reports, have powerfully perpetuated the stigma and burden of mental illness, adding to the weight of hopelessness and shame mentally ill patients already carry.
If a drug makes them feel worse, it's not the right drug.
Patients fear psychiatric medications might alter their personality, make them feel like a zombie, or impair their ability to think clearly and function normally. However, the right medication should improve or resolve symptoms, including cognitive symptoms associated with mental illness, and help them to regain their optimal functioning.
Inappropriate prescribing, inadequate physician resources to monitor treatment, delayed treatment, failure to manage side effects and symptoms of anxiety add to the risk of developing negative perceptions about treatment and treatment failure. In the wrong hands, any medication can cause harm, but when prescribed appropriately psychiatric medications are compassionate, effective and sometimes life-saving.
The trouble is, there is no recipe book for prescribing psychiatric medications. Every individual is unique, so with the guidance of their doctor, patients must find the treatment that's right for them. If a drug makes them feel worse, it's not the right drug, but that doesn't mean there are no other options. The right treatment must be found and sometimes that takes time, effort and creativity. Feeling like a zombie is never an acceptable outcome.
When a mentally ill patient doesn't get better with the usual treatments, they are often referred to a psychiatrist. If there is no psychiatrist to refer to, or the wait is months or even years, patients may remain untreated or continue to take ineffective or intolerable treatment, reinforcing their belief that medications don't work or that they cause more harm than good.
The trouble is, there is no recipe book for prescribing psychiatric medications.
I encourage my new patients to start the search for the right treatment by providing them with education and instilling hope. I say, "I want you to love your drugs" because with the right treatment there is hope for a full and sustained recovery. For our work to be a success, patients shouldn't feel "medicated". Ultimately, they should feel and function like they did before they got ill. The journey begins when my patient is armed with a plan, information and a sense of optimism.
Unfortunately, sometimes within hours of our meeting, that optimism is shattered. Whether by a pharmacist* making an ill-advised comment, a confidante voicing an indignant, uninformed opinion, or Dr. Google, my patient's lingering fears are reignited. Comments like, "You don't need that drug. I have a homeopath/ shaman/ Vitamin B complex that worked wonders for my friend", can powerfully undermine an anxious, ill patient's resolve, causing their new insight and game plan to be forgotten.
So what's wrong with relying on something other than medication for a serious mental illness? Prolonged suffering. Worsening long-term functioning. Destruction of relationships. Unemployment. Cognitive impairment. Refractory illness. Suicide.
I am a strong advocate of psychotherapy (abundant evidence), exercise (grows brain cells), yoga/ mindfulness/ spirituality (growing scientific evidence) or whatever else floats my patient's boat, but when you need medication, nothing else will do. These approaches may be helpful augmentation strategies for severe mental illness, but they cannot carry the weight alone. One lovely patient said to me, "I tried so hard, but I finally had to accept that I couldn't yoga my way out of my depression".
Sometimes the journey requires that my patients muster seemingly infinite patience, which is so difficult when you feel miserable. I ask them to... never give up
While I truly hope my patients will ultimately love their drugs, not everyone does and the search for their best treatment must continue. Sometimes the journey requires that my patients muster seemingly infinite patience, which is so difficult when you feel miserable. I ask them to never, never, never give up, and I won't either.
Every day I witness the insidious pressure and shame Abby described. Patients I have known for many years, who trust me and tell me they feel better with treatment than without, say they face a daily internal struggle when deciding to take their medication.
I just don't understand why folks aren't thrilled that we have medications that are safe and effective for the majority of patients with severe mental illness. If we didn't have them, we'd be wishing we did.
*Note to pharmacists -- I am one of you, but this happens almost daily in my practice.
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