Last year, I blogged about a fictional patient, Lillian, who was hospitalized for an infection. While there, she was told by the admitting doctor, someone she had never met, that she was taking too much medication for her mental illness. She was so frightened by the comment that she stopped taking her medication with disastrous consequences.
This happens far too often: a doctor that has no knowledge or understanding of why a treatment was prescribed tells my patient they are taking too much or too many psychiatric medications. Worse still, I've had psychiatrist colleagues do the same thing. It can sometimes take several years and many treatment trials to find the most effective, tolerable medication, yet with a single glance, that doctor knows better?
To be clear, not everyone who has a mental illness requires medication. There are many evidence-based treatments, such as talk therapy, exercise, light therapy and lifestyle changes, that can help to promote and maintain mental health.
While it might not be a personal attack, a colleague discrediting me without knowing anything about the process that led to my patient's current treatment sure feels personal. It's also unprofessional, inappropriate, and potentially harmful to patients. Yet, this has happened twice in the past three months in my practice.
Why? I think it's due to stigma.
"Doctors, including psychiatrists, perpetuate stigma." I heard this from the leader of a prominent mental health advocacy group and I remember feeling incensed. Psychiatrists have chosen a profession that is completely focused on caring for mentally ill patients. How can we be accused of stigmatizing mental illness? Now, I think he was right.
Mental illness has always been highly stigmatized. Mental Health Month and other awareness programs attempt to bring mental illness out of the shadows, yet many of those who should be leading the fight to de-stigmatize mental illness, my fellow physicians, continue to foster stigma through their actions and words. Many patients have been irreparably harmed by physicians from every area of medicine who don't read, don't listen, and don't care about mental illness.
Not that long ago, mental illnesses were commonly viewed as a reflection of weakness. Military members with PTSD were sometimes labeled "LMF"- short for low moral fiber. Now we know better, or at least we should. Chronic mental illnesses actually reflect an injured brain. Inflammation, brain cell loss and damage, and changes in brain chemicals provoke and perpetuate mental illness.
We now know that mental illness must be treated with a sense of urgency because rapidly reducing symptoms limits the damaging effects of the illness on the brain. We must also treat mental illness fully: even if the sadness is gone, ongoing symptoms like insomnia, fatigue, or trouble concentrating or remembering pose a substantial risk for depression relapse. Finally, we must aim to restore functioning: helping patients to get back to work, back to life and back to love.
Hypertension and diabetes are now recognized as chronic inflammatory diseases that must be fully and effectively treated to prevent heart attack or stroke. Diet, exercise, stress reduction and medication are all employed to prevent those serious negative outcomes and it's not uncommon to use two, three, even four medications to fully manage these disorders.
We also have powerful evidence that inflammation plays a central role in the development, severity, and recurrence of chronic mental illnesses. Exercise, diet, stress reduction, psychotherapy, and medications are all important tools for treating the illness and preventing relapse, which also protects physical health.
The greatest advocates for mentally ill patients should be doctors. We must lead by example and take better care of ourselves and each other.
If a mental illness is serious enough, medication is necessary. Yet despite the evidence, prescribing a combination of medications to fully treat a mental illness is viewed by some physicians as inappropriate, unnecessary or even dangerous.
Much like yelling at your pancreas will not result in increased insulin production, you can't tell a severely depressed brain not to be depressed anymore or demand that a hallucinating brain stops hearing voices. Yet, by saying, "You shouldn't need medication" or "You shouldn't need that much medication", a doctor is suggesting that a patient should be strong enough to get over their illness on their own, without adequate treatment. This implies weakness and further isolates patients that are already suffering.
What if it takes 3 or 4 or 6 medications for my patient to get well? What if, as a result of those medications, my patient is productive at work, they're parenting effectively and they're not experiencing side effects? It really shouldn't matter how many medications are required, so long as they are prescribed rationally and safely and my patient is happier, healthier, and more functional.
Many doctors don't admit when they're mentally ill, not even to themselves, which has resulted in alarmingly high suicide rates. I think that is also a reflection of stigma. The greatest advocates for mentally ill patients should be doctors. We must lead by example and take better care of ourselves and each other. If our attitudes don't change, many who struggle with mental illness will continue to suffer in the shadows, unseen by those who can and should help.
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