Yes, another thread on psychiatric medications. The usual question, of course - are they lifesavers? Are they just a crutch to keep us sedated? Is there a middle ground? There’s a really intriguing debate going on in brad_mac2’s thread in MPSIMS, and I think it deserves a home of its own. So here we go.
Personally, I think this is the sort of thing that can only be honestly decided on a case-by-case basis. Misdiagnosis happens. Overdiagnosis happens. Overmedication happens. It’s important not to put blind faith in psychiatrists or therapists, because they don’t always know what’s right or best, and their own prejudices can blind them to the facts. On the other hand, there is scientific evidence that at least some people with diagnosed mental illness really do have physical differences in their brains that cause a lot of unnecessary suffering. The brain is an organ. It can malfunction. And some people really do need medicine for it. I do, for one.
The important thing, for me, is to not make blanket pronouncements. Medication is not appropriate in all instances. It is, however, appropriate in some. Psychiatry is not a giant swindle, nor is it the greatest thing ever in the history of mankind. It’s just flawed humans trying to work with human flaws. Sometimes it’s great. Sometimes it’s awful. But it’s our best attempt so far.
Anyone else want to chime in? AHunter3? Guin? Wesley Clark? Metacom? Or anyone else I’ve forgotten?
I was recently reading a Newsweek special on future medical tech. they said one of the problems with depression is that some people carry a gene abnormality that causes them to produce small amounts of serotonin. As a result conventional SSRIs do not work as all they do is keep serotonin in the synapse. But since those people don’t have alot of serotonin to start with, the drugs don’t work.
Some people are born with extra amounts of serotonin. Some are born with a small amount. Taking a drug to give you a biology that is (relatively) closer to someone who is genetically differnet is not a form of cheating IMO.
I am genetically muscular. Even though I don’t work out I still have more muscle mass than about 95% of the male population. If someone wants to take protein or creatine to develop a muscular frame similiar to mine I am not going to complain about it, they are just taking control of their lives by using chemistry to create a body similiar to those that some people are genetically endowed with. On the same token, I was born with a shitty brain. Depression & mental illness run in my family so I cope by providing my brain with nutrients (building blocks, methyl donors, essential fatty acids, vitamins) it needs to become like those who are just genetically prone to being happy and competent. The point is, I don’t condemn those who use nutrition or pharmacology to accomplish what I ‘accomplished’ genetically, and I don’t expect to be condemned for using nutrition or pharmacology to accomplish what others have accomplished genetically. Biology is biology, irrelevant of whether it is created by genetics or manmade chemicals.
Of course there is a gray area, ie is it ok to use steroids & growth hormone because others have biologies that produce excess amounts of these chemicals, is it ok for endurance athletes to use cancer drugs to build up hemoglobin because some people just build more hemoglobin naturally, etc.
I know its radical, but I have no problem with legal drug use (I have to say legal). It is the individual’s body and they should do what they want with it.
I can see why people would consider it cheating, but I do not personally have a problem with it. I’d rather control my biology rather than blindly accept whatever genetics writes for me.
The problem with medication, and more generally the classification of mental illnesses and disorders isn’t that they don’t work/aren’t applicable–clearly, many people manifestly benefit from drugs and therapy based upon standard diagnoses–but that the entire field of psychiatry and psychopharmacology is just barely elevated above the level of pseudoscience and black art.
Take anti-depressants, for instance; while for some, they may be “just a crutch” that lets them avoid dealing with normal anxieties, for many they are a tool that helps them by letting them create coping strategies without being overwhelmed by anxiety and needless dispair. Anti-psychotics allow many to at least be marginally functional rather than to be raving lunatics or alternating between catatonia and mania. But no psychistrist knows with any degree of certainty what medication and dosage is likely to have effect on any patient; at best, they can prescribe based upon the type of disorder and apparent intensity, but such prescriptions often have to be adjusted repeatedly until they get to some suitable level, then monitored continuously for change or side effects.
Ditto for the process of diagnosis; for convenience’s sake, mental health practicioners try to guide a patients symptoms into one or more established pathologies per the DSM or ICD. The problem with this is that these classifications are created on the basis of the very symptoms they are classifiying; in other words, they’re grouped together because they have similar effects, not necessarally because all symptoms extend from the same (often unknown or poorly understood) root cause. By this logic we would classify flies and eagles in the same taxa based upon the commonality of winged flight even though they are the result of convergent evolution on distinct clades. The most recent version of the DSM (-IV) is much better, or at least much more flexible, about this than earlier versions, and comparing the two finds a vast amount of change between early diagnosis and present pathologies. Nonetheless, the diagosis process is not only highly subjective on the part of both the clinician and the patient but also generally lacks an understanding of the biological root causes of the problem.
From a psychotherapy standpoint this isn’t as much of an issue, since the therapy deals with processing through whatever issues exist via the brain’s own mechanisms, with perhaps a little chemical assistance in pill form (or more rarely, a touch of current). From a pharmecutical and psychiatric position, however, this represents a gross lack of functional control; without understanding how different medicines affect neurochemical modification and how the chemistry of the brain varies from disorder to disorder (and individual brain to individual brain), psychopharmacology is more like playing Pin The Tail On The Donkey than treating a specific disorder.
This leads many people, not all of them Hollywood stars belonging to tax shelters formed by bad science fiction authors, to dismiss theraputic psychotropic medications entirely, which is unfortunate because, as stated above, even with our nearly-blind bumbling diagnosis and fitfully hopeful treatments, they do help many people who in past times would be consigned to an asylum or an attic room. But we’ve got a long, long way to go before we can start referring to psychiatry as a science without suppressing a contemptious snort.
I find it hard to improve on what Stranger on a Train said.
I will say that for many of us, our experience of psychiatric medication is that it is far far worse than its absence. (As Guinastasia and others often note, this is not true for everyone).
Now kindly step back with me so you can see what the big picture looks like from this vantage point:
• As per Stranger on a Train’s overview, the mental health and pharmaceutical professions lie about how much they know about these conditions and how good their drugs are. They have sunk an incredible amount of money into convincing the general public that their claims are solidly supported by scientific evidence and that it is sound medicine and responsible public policy to diagnose mental illnesses and treat them. But not only are they bumbling around in the relative dark and offering up rather clumsy treatments that don’t work as simply and effectively and they’d like to have you believe — their treatments are also demonstrably risky. Most antipsychotics (anti-schizophrenia and anti-bipolar meds) cause permanent brain damage, with the risk rising the longer you stay on them; and anti-depressants, until just recently the poster child for successful psychiatric pharmacopia, turn out to have a high rate of paradoxical inverse effect (e.g.,precipitating suicidal behavior) as well as a host of other widespread unpleasant effects. And the pharma companies have been caught trying to cover it up and are getting investigagted or sued in several countries.
• There’s a lot of involuntarism stirred in. First you have your blatant variety (involuntary commitment, forced treatment via literal physical coercion). Then you have involuntary outpatient commitment (“If you don’t take this pill we’ll lock you up again for noncompliance”). Then you have indirect threats and provisions (“Let’s get rid of cheap housing and replace it with housing programs in which, in order to be a resident you have to take whatever meds are prescribed for you” / “Let’s test all the schoolkids and make compliance with psychiatric treatment recommendations mandatory for attendance”)
• As I said, above, many of us find the treatments grossly unpleasant. Mind-robbing. An assault upon the self more severe than any mere physical attack. It is very difficult to separate out how much difference it makes to choose a mind-altering substance (and to be able to choose to discontinue it at any point) rather than to have it imposed (and to see, stretching in front of you, no end in sight). Certainly I do at times choose to take antihistamines, voluntarily accepting a nasty bit of brain fog for the privilege of halting a full-blown allergy attack. Informed consent really makes all the difference. And that is why I tend to pop into these threads. People who solicit opinions about psychiatric treatment (or otherwise bring the subject up) are most likely to have heard the mental hygiene lies. Contrary to what some may think, I am not trying to keep people from accessing psychiatric treatment. I just want people reading these threads to know about the risk of forced treatment, the range of negatives about the drugs, and the true state of knowledge / ignorance about these conditions that the mental health system actually possesses. Informed consent. Know that they can take away your right to say “no thanks”, and know what it is you’re saying “yes” to.
PS — I would like to open such a thread some day and see that a happy consumer of psychiatric services who has already posted has put disclaimers in their post: “Be aware that, while psych meds have saved my life and put me back on my feet, some folks have had very negative experiences with them, and that sometimes force is involved (although no one has ever tried to force psychiatric treatment on me against my will, it does apparently happen). They’ll probably be around shortly to tell their side of the story”.
Something like that. Because I (and others who share my general opinion of the matter) almost always put in disclaimers about how some people have very good results with these treatments and give glowing testimonials to their efficacy.
I’m not aware of evidence that the physical differences in their brains are a cause of mental illness, as opposed to a symptom or a side effect of psychiatric treatment.
I don’t think pharmacological psychiatry is our best attempt so far, if by “best” you mean “most helpful to the patient”. I think our best attempts so far involve treatment programs that revolve around providing an emotionally supportive atmosphere, humane and respectful treatment for the patients, and address their emotional, social, and spiritual needs rather then focusing on non-existant “chemical imbalances.” Such programs have existed, both in the present era and historically; the Quaker asylums in the mid 19th century being a good historical example. Unfortunately, such programs cost a lot more then drugs and periodic 20-minute visits with a psychiatrist.
If psychiatric drugs were the best treatment available to us, then we’d expect to see better results for psychiatric patients where such drugs are more widely used. There’s actually evidence that this isn’t the case; that schizophrenia patients actually have a better prognosis in third world countries then in the pharmaceutical-drenched US system.
1)Current psychopharmacology sophistication is more akin to alchemy than chemistry. The frameworks are crude, even if complex.
2)Psychiatry deals with the mind: the very seat of our being & identity. 1)There are existing folk notions (obviously), which are at odds, if not opposed, with the objective clinical approach. 2)There is more of a social engineering undercurrent to psychiatric diagnoses than a broken leg.
I can’t do it before you asked for it, but I’ve been saying this for years, if it makes you feel any better: psychiatric services have twice in my life made a huge change for the positive AND I have grave reservations about them.
I struggle with depression periodically. Twice, it’s gotten so bad that I went to a counselor and a doctor. I took medication to help me think clearly, so the counselor could help me find my way out of the mire. I encountered numerous idiots posing as counselors along the way, and dumped them posthaste. The last counselor I ever spoke with is my personal hero to this day. At our second meeting, she said, “I want you to be very clear about my objectives. I want you healthy, off medication, and out of my office as soon as possible. My goal is to help you and send you off, not to make money off you. Therefore, I will not tolerate any BS from you about not being able to help yourself. When you are truly struggling with something, I will help you. When you are too lazy or too frightened to do anything, I will call you on it. Can you work within this framework?” I fell on her neck in joy. Her approach was the best for me, and I think it would be the healthiest for most people.
HOWEVER, my mother is on medication and will be for the rest of her life because she refuses to confront or change the problems that make her so depressed. I think this is stupid, and unfair to herself and those that have to deal with her. My sister, who would take too long to explain, was twice involuntarily committed, and made to take medications that basically transformed her into a quiet drool machine. This did not advance her mental state, or anyone else’s. I would like to strangle both the misguided doctor that keeps prescribing for my mother, and the rampant fools that messed up my sister.
I think medication is sometimes useful and should be used only as a last resort.
I think counseling is sometimes useful and should be undertaken with great caution, and maybe a pickaxe.
If I need help again, I will get it, but I will do it cautiously, and with as much information as I can get.
AHunter3, is that the sort of thing you’d like to hear?
One thing I have not yet heard discussed is that these issues are different for different mental illnesses.
There is strong evidence that schizophrenia and bipolar disorder have a biological basis. On the whole, they conform fairly well to the medical model of illness. There is much weaker evidence of this for depression and anxiety disorders.
For bipolar disorder, there has been a lot of clear-cut success with pharmacological therapy. For 70 percent of bipolar patients, one drug–lithium–eliminates or greatly reduces the symptoms. The remaining 30 percent typically have moderate to excellent success with anticonvulsant medications. Therapy alone rarely provides any appreciable improvement. The disorder almost never remits of its own accord. Pharmacological therapy is therefore clearly indicated.
The story is quite different for unipolar depression. Success rates with medication alone are under 50 percent, and the typical patient must try multiple antidepressants before finding one that alleviates symptoms. Furthermore, studies find that the best results come with therapy in combination with medication, and even then success rates hover around 65 percent. Left untreated, it is not uncommon for depression to remit of its own accord. To further muddy the picture, there appear to be multiple “types” of depression, each with their own particular set of quirks–how severe the symptoms are, how well they respond to medication, what medications they respond to, how likely they are to remit of their own accord, etc. The case for pharmacological therapy for unipolar depression in general is therefore quite murky.
Perhaps a bit offtopic here. I grew up in a world where destruction by nuclear weapons was always a possibility. And I once knew a woman who was a diagnosed schizophrenic actually beg me to let her in my bed. I (foolishly at the time) refused her this request. Nuclear weapons seem crazy to me. On the other hand, compared to that this woman was all kinds of logical.
Lithium is relatively benign as full-blown antipsychotic meds go. Apparently the body attemps to use it as it would use sodium (similar chemical family) in certain processes — or so I was taught. It does tend to reduce both highs and lows, dampening out feelings, in a way that some bipolarites find horribly deadening (so forced treatment is still very much an important issue here), but it is not prone to cause permanent brain damage or the raft of nasty side effects associated with most other antipsychotics.
It does cause some rude liver toxicity if you get the serum level too high, and the level necessary for any effect is uncomfortably close to the toxic level, so folks on lithium have to get their blood serum levels checked pretty often.
Other meds inflicted upon bipolarites are more akin to schizophrenia meds and are decently well-described by what follows (except that they don’t tend to be quite as debilitating):
Schizophrenia meds are among the worst in the arsenal. Haldol, Prolixin, Navane, and other neuroleptics are blunt primitive brain-process busters. It’s not like being on Effexor! Here in particular you find people very unhappy with the psych meds that have been forced upon them (although, again, you will find some who will say that psych meds enable them to function and that they are very happy to take them). These are the medications that have been described as “chemical straitjackets”. They were not originally selected for the benefit of patients as the patients assess things, but rather for creating a manageable ward of pliable non-disruptive people. These are the meds you get shot up with if you get crossways with the staff on a locked ward and they consider you to be a discipline problem (regardless of your diagnosis, by the way!). The theory that the meds address a “chemical imbalance”, and that schizophrenia in some fashion is a condition marked by the inverse of what these pharmaceuticals do, is an aftermarket add-on notion, and not a notion with any support. (Schizophrenia is most definitely not a Haldol-deficiency disease).
So the basic point is that most psychiatrists are very nice people who try and losten and help you move past your problems, but don’t really have much beyond a selection of oddly-shaped hammers aside from that?
[QUOTE=AHunter3]
Lithium is relatively benign as full-blown antipsychotic meds go. *
Lithium is not an antipsychotic. It’s a mood stabilizer. It is not related to any antipsychotic medication.
This varies a great deal. It cuts off the highs and the lows, leaving the patient with a normal range of mood. Some people can’t get used to that, or don’t want to get used to that.
At higher doses, lithium is more likely to make a patient feel blunted or flat affect (no mood at all), but higher doses are not commonly used anymore.
In my personal experience, the people who feel lithium deadens their moods too much tend to have a self-destructive bent. They like the mania so much that they don’t care that they do things that seriously damage their lives and the lives of others. I take lithium for bipolar disorder. I miss some aspects of the highs, but I have enough maturity to realize that it’s better for me in the long run to maintain a normal range of mood. I do not find lithium deadening. I find that it has returned me to how I felt prior to the onset of bipolar disorder.
No one has ever forced me to take lithium or any other medication.
Your information is somewhat outdated. Doctors are now finding it is possible to maintain patients on much lower doses of lithium. This reduces the chances that blood levels will get too high and cause damage to the liver and/or kidneys. Once a patient is maintained on lithium, blood levels are typically checked quarterly or semi-annually. I do not consider this to be “pretty often.”
Anticonvulsant medications are NOT chemically related to antipsychotic medications. Anticonvulsants used to treat bipolar disorder are Depakote, Tegretol, Lamictal, Neurontin, and Trileptal, among others. Again, these are NOT like antipsychotic medications. They have their own special set of problems and side effects.
Some of the newer antipsychotic medications, such as Seroquel and Abilify, are now being used to treat bipolar mania. They are not anticonvulsant medications and are not traditional mood stabilizers.
You list the older antipsychotic medications. There is a whole new group of antipsychotics–the atypicals. The side effect profiles of these different types of medications are different enough that they should be discussed separately. In particular, the new antipsychotics are much less sedating, and patient compliance has been better with these medications.
Also, you keep talking about “forced” medication. Outside of the hospital, who is “forcing” anyone to take medication? Once you’re outpatient, it becomes a choice. You may feel that people are being coerced into taking these medications by their doctors, but, as with any medical procedure, it is up to the patient and their family to do their own research, seek second opinions, etc., to decide what is right for them.
New York (among other states) has involuntary outpatient commitment. They can send public health nursies to your door with your monthly Prolixin shot. They can have you picked up and returned to the locked ward if you decline to be injected. That’s coercive. That’s forced treatment.
Texas (among other states; and the Bush administration is apparently contemplating going nationwide with it) has heavy-handed policies demanding student compliance with medications that psychiatrists believe they should take. Illinois (and, again, it appears to be the start of a nationwide push) is gearing towards mandatory mental health screening of all schoolchildren. Also pregnant women, if I recall correctly. If MH screening is made mandatory and then noncompliance with meds prescribed can disqualify you from services, privileges, and etc., you’re going to see a whole new plateau of forced treatment on a frighteningly large scale.
The side effects and long-term toxicity of lithium salts is hardly as benign as you suggest. While, in moderate levels it doesn’t typically cause brain damage, there are concerns about long term metabolic adjustments to lithium including interference with kidney and thyroid function, espeically in people who may develop chronic health problems with these organs.
If I might make an observation, you seem (or at least come off as) wielding a bit of an axe with regard to this issue. It’s certainly true that pharmaceutical companies have been promoting SSRI-type antidepressants to a more general audience for the use of managing mild anxiety and managing unhappiness (as opposed to clinical depression); whether this is a legitimate and needful use of psychopharmacology is a suitible topic for debate in comparison to learning better social management skills, self-medication using alcohol or illegal drugs, therapy, et cetera.
However, schizophrenia is an entirely different ballgame; while it is possible, in some cases for some schizophrenics to manage their condition it generally results in an on-going effort; the root causes of (most) schizophrenias are, as Q.N. Jones states, neurological and are at least partially genetic in nature. Suffereing from depression brought on by a tragedy is one type of condition, most likely temporary; suffering from repeated cycles of catatonic depression and hyperactive mania with no cause whatsoever, or hearing and seeing hallucinations is entirely different and largely impervious to talk therapy. You might as well argue that a Tourette’s sufferer should just learn to shut up; while the latter can consciously control their outbursts when they pay attention, as soon as they focus on something else the tic returns. In both cases, medication, provides a relief from the impetus of their affliction. Strong psychoactives/antipsychotics are a last refuge for people with otherwise unmanagable biopolar or schitzophrenic disorders. It’s not a matter of the active isomers “replacing” a missing hormone, to respond to your statement that “schizophrenia is most definitely not a Haldol-deficiency disease.” Instead, they affect a change in the receptors; in the case of butyrophenone-type drugs, preventing the reuptake of dopamine.
Other disorders, such as ADHD, OCD, Tourette’s, et cetera, while not, in their lesser ranges, as debilitating as a schitzophrenic illness, can be best managed through a course of long-term medication. And even with conditions, like moderate persistant depression (dysthymia) or social anxieties that are transient or best dealt with by some form of psychotherapy, a short course of medication sometimes provides sufficient balance and an escape from the stressor that the patient can see the problem from an objective viewpoint and better accept the theraputic influence. It’s hard to convince someone who is sobbing with dispair or shaking with anxiety of the walls falling in that their problems are readily managable.
It is unfortunate that their is often a disconnect between psychiatrists, whose training in psychotherapy and many neurotic or non-schitzophrenic disorders is often minimal, and other areas of brain science and treatment (specifically, clinical psychology and neurology); and yet, because they have the medical background are often the only source for a pharmaceutical script. This is an extension of the basic problem in much of modern medical practice; to wit, doctors are trained to pathologize and treat individual illnesses but often ignoring the context of the illness. The general health and lifestyle of the patient is taken to be secondary to finding what bug is causing the problem and picking the drug to kill it. It doesn’t help that psychiatry is basically a tacked-on addition to medicine, advancing from Freud’s pseudoscientific statements and trying to integrate an imperfect understanding of both the philosophy of the mind and the biochemical functioning (neurology) of the brain. This leads to the notion that one (a biochemical imbalance) causes the other (mental disorder), or vice-versa (that, say, having a pessimistic attitude causes the neurological changes that we associate with depression), instead of realizing that they are two facets of the same issue, and in treating one you have to consider the interactions of the other. Giving a schitzophrenic medication may be critical in alieviating their disconnection from reality, but they also need to learn the skills of recognizing when an episode is coming on and how to cope with their condition emotionally.
The problem, as I said before, it that neither of these general areas of clinical treatment (psychopharmacology and psychotherapy) are consistantly effective for the majority of cases, and most people who are experienced in one small specialty of one of these areas are rarely well versed or even passingly knowledgable about others; while “talk therapy” might work well for one person, behaviorial conditioning might work better for another, and a third might be significantly more benefit from Xanax than from any lip-flapping. We don’t fundamentally understand which method to apply when, and as a result treating many “mental health” problems is largely a process of trial and error.
And some say that intelligence is an evolutionary milestone! I bet intestinal flora don’t have these kinds of trouble.
Yes, but how often and how easy is it to have someone committed? Usually, the way I understand it, they have to be a danger to themselves and to others.
You do realize that there are some people who SHOULD be committed, right? Let’s not throw the baby out with the bathwater.
The New York outpatient commitment statute is pretty strictly limited to people with very serious and recurrent problems that get them into big trouble on a regular basis.
It appears that inpatient commitment requires a significant risk of harm to self or others, not and.
Stranger on a Train, if I’m understanding you correctly you seem to believe the following:
[ol]
[li]That schizophrenia has a genetic component.[/li][li]That schizophrenia has neurological, has opposed to environmental, causes[/li][li]That most schizophrenics would be incapable of getting a handle on their life without drugs.[/li][/ol]
Am I correct in my understandings? If so, could you provide some cites?
yes!